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OXFORD MEDICAL
PUBLICATIONS

With the Compliments of the

Joint War Committee of the 'British

T^d Cross Society gf the Order of

St. John of Jerusalem in England

83 Vail Mall, London, S.ff.t.

PLASTIC SURGERY OF THE FACE

PUBLISHED BY THE JOINT COMMITTEE OF

HENRY FROWDE, HODDER AND STOUGHTON

17 WARWICK SQUARE, LONDON, E.C-4

PLASTIC SURGERY
OF THE FACE

BASED ON SELECTED CASES OF

WAR INJURIES OF THE FACE

INCLUDING BURNS

WITH ORIGINAL ILLUSTRATIONS

H. D. GILLIES, C.B.E., F.R.G.S.

MAJOR R.A.M.G.

SURGICAL SPECIALIST TO THE QUEEN'S HOSPITAL, S1DCUP

SURGEON IN CHARGE OK THE DEPARTMENT FOR PLASTIC SURGERY, AND LATE SURGEON IN CHARGE

OF THE EAR, NOSE, AND THROAT DEPARTMENT, PRINCE OF WALEs's HOSPITAL, TOTTENHAM

I.ATE CHIEF CLINICAL ASSISTANT, THROAT DEPARTMENT, ST. BARTHOLOMEW'S HOSPITAL

HON. FELLOW NATIONAL DENTAL SOCIETY OF AMERICA

WITH CHAPTER ON

THE PROSTHETIC PROBLEMS OF PLASTIC SURGERY

GAPT. W. KELSEY FRY, M.C., R.A.M.C.

SENIOR DENTAL SURGEON, QUEEN'S HOSPITAL, SIDCCP ; SENIOR DEMONSTRATOR AND DENTAL
OFFICER IN CHARGE OF THE 1'KOSTHETIC AND METALLURGICAL DEPARTMENT, GUY'S HOSPITAL

AND

REMARKS ON ANESTHESIA

CAPT. R. WADE, R.A.M.C.

LATE SENIOR ANAESTHETIST, QUEEN'S HOSPITAL ; ASSISTANT ANAESTHETIST, ST.
BARTHOLOMEW'S HOSPITAL ; ANAESTHETIST, GREAT NORTHERN CENTRAL HOSPITAL

LONDON
HENRY FllOWDE HODDER AND STOUGHTON

OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C.

1920

PRINTED IX OREAT BRITAIN

nv HA7.ru., WATSON AND TINEY, LT>.,

LONDON AND AYLESIH'HY'.

DEDICATED
I!Y SPECIAL PERMISSION TO

HER MAJESTY QUEEN MARY

WHOSE NEVER-FAILING INTEREST AND BENEFICENT
INFLUENCE HAVE BEEN A PERPETUAL SOURCE OF HELP
AND ENCOURAGEMENT TO PATIENT, DOCTOR, AND NURSE

INTRODUCTION

I HAVE had the pleasure of watching Major Gillies's plastic work since its initiation
at the Cambridge Hospital at Aldershot, and later at the Queen's Hospital
at Sidcup, where he and his British colleagues competed so cordially and so
successfully with the surgeons from the Dominions in their efforts to restore
the disfigured faces of the wounded to their normal form.

It was largely due to him that such rapid progress was effected in this
special and difficult form of surgery, of which little or nothing was known before
the war. Methods were employed and scrapped with great rapidity as im-
provements were devised.

It would be difficult to exaggerate the excellence of the work that was
done by the several surgeons. Advantage was taken of it by many Americans
and others, who profited greatly from observing the methods of treatment
that had been developed there.

This book, which is so handsomely illustrated, gives a very thorough account
of the many novel procedures which have been devised or elaborated at the
Queen's Hospital. It will afford an excellent basis for much civil work, and
I trust that special departments for plastic surgery will be started at the several
teaching hospitals, and that means will be taken to secure the services of those
surgeons who have had such wonderful opportunities to perfect themselves
in this special work. It is not sufficiently recognised how readily the skill de-
veloped in this branch of war surgery is directly applicable to the relief of dis-
figurements met with in civil life. Ugly scars resulting from burns and accidents,
deformities of the nose and lips, hare lip and cleft palate, abnormal protrusion
or ill development of the mandible, moles, port- wine stains, all abound, and are
not only the constant source of the greatest distress and anguish, but materially
lower the market value of the individual. There is also a vast field in the oblitera-
tion of marks of operative interference, such as removal of malignant growths.

This book, written by so skilled and experienced an operator as Major
Gillies, is invaluable to every general surgeon as well as to the plastic specialist.

I would also like to congratulate the publishers on the excellent manner
in which they have produced this volume.

W. ARBUTHNOT LANE.

September 1919.

vii

PEEFACE

PLASTIC Surgery of the Face is not a new development. Surgeons of all civilised
and some uncivilised countries have from time to time evolved methods of
repair for various disfigurements.

But not until the organisation of the new home Medical Service necessitated
by the late war, with the need for refinement in the matter of segregation of
cases in special hospitals so ably met by Lieut.-General Sir Alfred Keogh, our
late Director-General, has there been opportunity for anything but disjointed
study in this department of surgery.

In the later development of the work, the continuity of research was main-
tained by facilities afforded by his successor, Sir John Goodwin, for the retention
of the specially trained staff, in spite of the difficulties caused by the growing
shortage of medical officers.

The author wishes to place on record his thanks to Major-Generals Sir
Anthony Bowlby and Sir George Makins, and Sir Frank Colyer, who, in their
capacity as consultants, laid before the Director-General the importance of
organising means for the intensive study of this special branch of reparative
surgery.

The work on which this book is founded began in January 1916, at the
Cambridge Hospital, Aldershot, where, under the stimulus and able direction
of Colonel Sir W. Arbuthnot Lane, the treatment of war injuries of the face
and jaw was studied under suitable conditions in wards earmarked for the
purpose.

The author had the advantage there of co-operating with Captain L. A. B.
King, L.D.S., attached R.A.M.C., whose help as Chief Dental Surgeon through
that stern period of doubt, trial, and error was invaluable. The influence of
his work is still evident in our treatment of jaw injuries to-day.

A rapid increase in the scope of the work led to the removal of the hospital
to Sidcup, where, thanks to the sympathy and energy of Colonel Sir William
Arbuthnot Lane, Lieut. -Colonel J. 11. Colvin, and Major Waldron, C.A.M-C.,

Plastic Surgery of the Face
by H.D. Gillies, Oxford,
University Press, 1920.

x PREFACE

it was placed on an Imperial basis. The collection of the cases of facial injuries
from the British, Canadian, Australian, and New Zealand forces in one hospital
under their own medical officers has proved a factor of prime importance in
the improvement of methods of treatment.

Major Waldron and Captain Risdon (Canadian Section), Colonel Xewland,
D.S.O. (Australian Section), and Major Pickeril, O.B.E. (New Zealand Section),
and the officers serving with them, joined heartily in friendly rivalry and healthy
competition, to the great benefit of these poor mutiles.

Further, with the arrival of American surgeons in 1918 under Colonel Vilray
P. Blair, M.R.C.U.S.A., our wounded had call upon surgical, skill from the
whole Anglo-Saxon race. Each surgeon had the assistance of one or more
colleagues from the New World, to their mutual advantage.

NYcdless to say, the author realises his indebtedness to the numerous visiting
and consulting surgeons who from time to time have encouraged him by their
advice.

The knowledge of their interest and good-will has been a most powerful
stimulus towards perseverance in times when difficulties appeared insurmount-
able. He wishes particularly to thank Sir W. Arbuthnot Lane, Sir Francis
Farmer, and Sir Frank Colyer, among consultants ; and, among his British
colleagues, Major G. C. Chubb, Captains C. F. Rumsey, the late E. G. Robertson,
F. E. Sprawson, J. L. Aymard, R. Montgomery, H. C. Malleson, and A. L. Fraser
in the earlier part of the work, and later Captain T. P. Kilner, T. Jackson, and
Majors H. Bedford Russell and J. J. M. Shaw, M.C.

In particular, the stimulus of co-operation with Major Seccombe Hett has
considerably advanced the treatment of injuries to the nose ; while the pioneer
work of Captain King on the jaw has been maintained and further developed
by Captain W. Kelsey Fry, M.C., R.A.M.C., Chief Dental Surgeon, who has
written a chapter on the use of Prostheses in this work. In this connection the
work of Valadier and Kasanjian in France has been of great service in the
improvement of the treatment of jaw wounds. I am indebted to the former
for many photographs of the original conditions, and to both for the stimula-
tion of their work and for much kindly encouragement.

Among many American colleagues Captain Ferris Smith has shown himself
the most constructive critic the author has had the pleasure of knowing. He
was of great assistance in the preparation of the early proofs of this work.

Not a small feature in the development of this work is the compila-
tion of case records. The foundation of the graphic method of recording
these cases lies to the credit of Professor H. Tonks (Slade Professor), many
of whose diagrams and photographs of his remarkable pastel drawings adorn
these pages.

PREFACE xi

Unfortunately, his other duties forbade his taking as large a part in the
work as he and we ourselves could have wished. Latterly, his work has
been ably carried on by Mr. Sidney Hornswick, who, on his own initiative,
has considerably improved and standardised methods of recording flap
operations.

The compilation of notes in the early part of our work was carried on
voluntarily by Mr. Thomas Pope. The author cannot sufficiently thank him
for the sterling value of his work and the loyalty with which he persevered
at his self-appointed task through two full and difficult years.

Lieutenant J. Edwards has not only been responsible for the preparation
of routine plaster-cast records, but for a very important part of our work,
the reconstruction of features on the casts as a preliminary to surgical
reconstruction.

Herein, guided by the surgeon in the matter of surgical possibilities, he
strives, sometimes for the ideal, more often for the best possible surgical com-
promise ; and his work calls for constructive imagination of a very high
order. Where chances of surgical repair are not evident he co-operates with
Captain Fry in the provision of as perfect a mechanical restoration as
possible.

In the X-ray Department Captain H. Mulrea Johnston has displayed great
ingenuity and resource in evolving standard positions for radiographic
records, particularly of jaw injuries. Latterly, his place has been ably taken
by Captain R. A. C. Rigby.

The majority of the photographic figures in the book have been prepared
by Mr. Sidney Walbridge. Their excellence speaks for itself, but gives no
idea of the time and care this late N.C.O. has devoted to ensuring that they
shall be an honest and true record. He has had to suborn his art to this end,
sternly suppressing the temptation to manipulate the lighting or retouch the
negatives.

The work of correcting later proofs has been kindly undertaken by my
colleague, Mr. H. Bedford Russell. The heavy secretarial work has been chiefly
performed by the author's patients (for the most part E. J. Greenaway ; partly
also R. W. D. Seymour), who have stuck to their task with persistent, cheerful
loyalty, in the intervals between their operations.

The author takes this opportunity of thanking his publishers for their oft-
tried leniency in regard to delays in the production of " copy." In extenuation,
he would plead a strong penchant for laying aside the pen in favour of the
scalpel whenever a plastic problem presented itself.

Above all, the author cannot adequately express what he owes to the loyal
co-operation and assistance of the medical officers surgeons, physicians, and

xii PREFACE

ana-sthetists alike and the Matron, and the theatre- and ward-nursing staffs
of this hospital, whose shoulders have borne the brunt of the work. Assiduous
and intelligent care in the after-treatment of these eases is a prime necessity,
and calls for the highest standard of watchful skill.

Finally, the author wishes to thank Lieut. -Colonel J. R. Colvin, Com-
mandant of the Queen's Hospital, for his unfailing help and fairness of treatment
throughout two long years. His powers of organisation and ready grasp of
the situation have alone rendered possible the continuity of the work in times
of stress.

H. D. G.

February 1920.

CONTENTS

CHAPTER I

PAGE

PRINCIPLES : HISTORICAL ......... 3

CHAPTER II

REPAIR OF THE CHEEK . . . . . . . . .37

CHAPTER III

INJURIES OF THE UPPER LIP ........ 77

CHAPTER IV

INJURIES OF THE LOWER LIP AND CHIN ...... 123

CHAPTER V

PROSTHETIC APPLIANCES IN RELATION TO PLASTIC SURGERY . . 193

CHAPTER VI

INJURIES OF THE NOSE ....... .211

CHAPTER VII

INJURIES IN THE REGION OF THE EYES, INCLUDING BURNS OF THE FACE 300
INJURIES TO THE PINNA ......... 381

CHAPTER VIII

PLASTIC SURGERY IN CIVIL CASES 391

INDEX 401

PRINCIPLES

CHAPTER I
HISTORICAL

THE origin of plastic surgery is of the greatest antiquity. From time
i mmemorial rhinoplasty has been performed in India for the relief of the dis-
figurement caused by punitive mutilation of the nose. Two methods appear
to have been employed, though the forehead-flap is the only one the use of
which has survived in India to this day.

A method embodying the use of cheek-flaps is described in the Ayurveda,
the sacred medical record of the Hindoos, but it has had to yield to the forehead-
flap method a striking parallel to what has occurred in Europe in the last
few centuries. The French (or German) cheek-flap method has been relegated
to the lumber-room of surgery, and a development of the Indian method, which
includes the important improvements evolved by Keegan and Smith, has pride
of place Jx^djiy.

In perusing the literature of this subject, one is struck chiefly with the
lack of appreciation of the need for a lining membrane for all mucous-lined
cavities. Not until Keegan's time was it given any prominence, and perhaps
even he did not appraise it at its true value. And so it is that the various
classical methods take their name from the covering flap employed. In actual
fact, except that forehead skin most closely resembles nose skin, the origin of the
covering is the least important part.

The Italian method, which originated apparently in Sicily about 1415
and was developed by Tagliacozzi in Italy forty years later, consists in the
transference of skin for a nose-covering from the patient's own arm, in two
stages, the patient being immured in a fixation apparatus while the flap takes.
This method was feasible in those stern times, but the more than irksome fixation
is not tolerated by the modern patient, and it has been discarded. The principle
on which it is based, however, is of wide application, and a modification of it,
the author's tube-pedicle method, is in routine use for some of our operations.

As in rhinoplasty, so in the rest of present-day plastic work, the principles
laid down by the fathers of surgery are found still to be of general application.
There is hardly an operation hardly a single flap in use to-day that has
not been suggested a hundred years ago. But our work is original in that all

4 PLASTIC SURGERY

of it has had to be built up again de novo. It does not fall to the lot of every
surgeon to see even one chciloplasty in his training.

The earlier months, then, were spent in a very thorough trial of the then
known methods. It has been illuminating to discover the impracticability
of many of these, which would appear to have been put forward on the study
of one case only, or even on purely theoretical grounds. Among the sponsors
of really practicable methods the names of Tagliacozzi, Nelaton, Keegan, and
Smith stand out prominently.

PRINCIPLES

It is the author's aim here to discuss principles in the order of their ap-
plication in a given case. They will thus be dealt with, in the following order :

HISTORY, ETC. ANESTHESIA.

EXAMINATION. OPERATION.
EARLY TREATMENT. General Technique.

PLANNING THE REPAIR. Stages.

1. Lining Membrane. Suture.

2. Contour and Supports. Dressings.

3. Covering Tissues. After Treatment.

HISTORY, ETC.

The history of the injury is obtained, together with any existing record
of the early condition, and if possible of the condition prior to injury. It is
of importance also to obtain information as to the presence of luctic or tuber-
cular taint, and as to the patient's healing powers as shown in former operations.

EXAMINATION

The majority of failures in plastic surgery are due to errors the commission
of which would lead to failure in any form of surgery. Thus, mistakes in diagnosis
due to inadequate examination are perhaps the commonest cause of indifferent
treatment. This element of difficulty in diagnosis may not at first sight be
obvious. The word diagnosis in this work is used in its literal sense, namely,
to mean a thorough knowledge of the condition present i.e. the exact loss in
terms of anatomical structure.

The routine examination of our cases, with preparation of records of the
condition on admission, occupies nearly a week ; but the time so lost is regained
a hundredfold. The examination merely of the surface of. the lesion, simple as

PRINCIPLES 5

it would sound, is fraught with dangerous pitfalls. One has seen a case in
which a point a quarter of an inch above the angle of the mouth really belonged
to the infra-orbital margin. The tissues had been stretched to this extent
without dragging down the lower lid to any marked degree, and one might
have been forgiven for regarding the stretched skin as part of the cheek.

Here, as elsewhere, the aim is to estimate first the amount of loss ; and,
secondly, the possibility of correcting displacement.

It is often impossible to do so till one has undone some previous effort at
repair.

A moment's consideration will show that no estimation of the loss or dis-
tortion of soft tissues can be of use unless coupled with a knowledge of the
condition of the bony tissue. When there is greater loss of the underlying
mandible than of the skin, one is apt to conclude that there is no great loss
of skin. In such a case, one must visualise a completely restored mandible,
and then judge whether the remaining soft tissues are sufficient to cover it.
In this connection, if a photograph is obtainable of the condition before injury
it will often be of great assistance. In the case of any organ forming the wall
of a mucous cavity, such as the lip, it is necessary to make an accurate estimate
of the loss of mucous membrane. In fact, estimation of loss should be made
separately in regard to (1) the mucous lining, (2)- the bony or cartilaginous
support, and (3) the skin covering. The estimation of bony loss necessitates
intranasal and intra-oral and radiographic examination in addition to surface
palpation, and even then is often difficult to make in cases where the injury
is symmetrical. One has seen an intrinsically well-made nose constructed upon
a bed at least one inch posterior to the normal plane : the loss of the nasal spine
and premaxilla had not been taken into consideration, and the face, to the
surgeon's disappointment, presented an undershot appearance.

To overcome such difficulties, Surgery calls Art to its aid. A^ pi aster cast
of the face is made, and thereon the sculptor, aided by early photographs if
available, models the missing contours. With radiographs to confirm that the
apparent loss is not merely displacement, the surgeon now has data for adequate
diagnosis.

EARLY TREATMENT

The diagnosis established and recorded, the surgeon plans his repair. The
first principle is one which the author believes to govern the whole treatment
of facial injuries, and this is that all jiormal jjssue_sh m ild be replaced as early
asjjossible, and maintained in its normal position. In treating an early wound
there is a natural disposition to try to close unsightly gaps. More harm than

6 PLASTIC SURGERY

good is done thereby, as the reactionary swelling and the frequent suppuration
cause more scar tissue than would otherwise have to be dealt with, and the
stitches only too often give way. In addition to this undue stretching of the
damaged tissues, the early cutting of flaps is, in the author's opinion, to be
condemned ; for, even when this procedure is successful, no obvious gain in time
or appearance is obtained, while considerable risk of suppuration is run. It
follows, therefore, that split lips, lacerated noses, and gashed cheeks, where
the loss of tissue is negligible, should be carefully sewn up with drainage as
soon as possible. Every effort should be made to replace tissues in their normal
position by stitches, strapping, head-gear apparatus, nasal supports and splints,
but never into abnormal positions. There is one exception to this which de-
serves mention, namely, that tags of mucous membrane should, faute de mieux,
be delicately attached to any neighbouring raw surface to preserve their form
and vitality.

In the very common facial injury, where one of the mucous cavities is
involved in the wound and the loss is so great that the repair cannot be done
without undue stretching, the modern practice of excising the wound should
be brought into play, and then the skin sewn to mucous membrane round the
margin of the defect. This should be done wherever possible, so that as little
raw area as possible is left to granulate. In dealing with lacerated mucous
membrane, the greatest delicacy of touch must be used, and in effecting the
suture as little manipulation of the tissues as possible should be indulged in.
A corollary of this belief of the author's is that in clearly defined gaps of the
mandible, the end of the bone should be smoothed off and the buccal mucous
membrane sewn across the raw bone, a procedure advocated by Trotter. Were
it possible of achievement as a routine, it would almost certainly prevent ci-
catricial approximation of the fragments ; but one realises that, with many
other suggestions for early treatment, it is a counsel of perfection, and, in very
severe injuries, may well be impracticable under conditions of active warfare.

In the early treatment of all wounds involving the oral cavity the dental
surgeon must be encouraged to take a large share of responsibility. His treat-
ment will begin naturally with a general nettoyage of the alveolar area. Loose
and septic teeth and stumps must be extracted, and, as soon as can be accurately
determined, the teeth obviously in the line of fracture (the persistence of which
is not of vital importance for the fixation of the fragments) should be removed.
Frequently the decision as to whether a tooth is or is not in the line of fracture
has to be modified, and it may become necessary to remove more teeth than
was first expected. The most careful watch for persistent pockets of pus must
be maintained.

In many cases it will be found of great advantage to provide infra-mandibular

PRINCIPLES 7

drainage on to the neck surface beneath the various lines of fracture. This
sounds reasonable and simple, but in practice it is found quite difficult adequately
to drain some classes of comminuted fractures, and the mandibular remains
are apt to carry on their existence in a sump of pus (visually, one must admit,
with considerable success !).

For this as well as for general reasons, the passive drainage is greatly assisted
by frequent forcible irrigation, the Carrel continuous irrigation being not always
practicable in this region.

By adequate drainage alone are the dangers of secondary haemorrhage
avoided, and it is one's experience that those cases in which there is a small
perforating wound of the body of the mandible are most prone to this disaster.
One has never seen a serious haemorrhage in a case of facial wound in which
the loss of bone and soft tissues is great, and it would almost seem advisable
that these small wounds should be considerably enlarged, and skin sewn to
mucous membrane to make these openings persist till secondary suture can
be safely undertaken. The author does not propose to dilate upon the treatment
of secondary haemorrhage.

Apart from this dental toilet, the chief role of the dentist lies in controlling
the bony fragments. The author is disappointed with the results of the so-called
suspensory wiring of fragments, which involves the wrong principle of putting
foreign bodies in contact with inflammatory bone lesions. The facial surgeon
has the advantage of the orthopaedist, in that his instrument-maker is a pro-
fessional colleague who has for his goal the provision of the best masticatory
result. The dental surgeon must be fully alive to the possibilities of his surgeon
and of surgery in general. Thus, in the early days of bone-grafting, many
wide gaps of the mandible were brought together by the dental surgeon in the
early stages in order to get bony union in a shortened mandibular arch. With
the rapid success of mandibular grafting this procedure has become extinct,
and it is the author's opinion that it is rarely justifiable to shorten the mandibular
arch. The class of case where it is permissible is that in which the patient
is edentulous, and the loss of bone minimal.

PLANNING THE LATE REPAIR IN A TYPICAL CASE

A man with loss of the upper lip, say, arrives from France with the remains
sutured across beneath his nose and possibly healed there. Frequently the
first step is to reconstitute the wound by the release of the overstretched tissues.
The mucosa of the lip stumps is then secured by suturing it to skin over the
raw edges. This very important measure should be employed by the first
surgeon who sees the case after injury. Only now, as a rule, is it possible really

8 PLASTIC SURGERY

to diagnose the loss and plan the restoration. (Sometimes this replacement
of the first stage of any plastic operation can be imitated by moving putty flaps
upon the plaster cast as one would the flesh.) In planning the restoration,
junction is the first consideration, and it is indeed fortunate that the best cos-
metic results are, as a rule, only to be obtained where function has been restored.
Perhaps the first question that arises in any case is the relative expediency of
attempting surgical repair or mechanical camouflage, and a satisfactory decision
can be arrived at only as a result of long experience. Sometimes in the end
the repair undertaken is a compromise between surgery and mechanics, the
decision being based on the severity and multiplicity of the operations needed
to effect a surgical cure, and on the patient's lack of stamina ; or on factors
outside the present discussion. One looks forward with confidence to a plastic
millennium when, given a healthy patient and no time restrictions, it will be
possible to cope surgically with any reasonable facial loss.

The restoration is designed from within outwards. The lining membrane
must be considered first, then the supporting structures, and finally the skin
covering.

Lining Membrane. Omission to provide a lining membrane for mucous
cavities has in the past been the supreme cause of plastic failure. Kcegan
quotes a President of the Royal College of Surgeons in 1863, as mournfully
describing how a well-shaped plastic nose is prone to wither away on the patient's
face. The author has seen examples of a similar occurrence in recent times,
for want of a lining ; and many cases of post-operative nasal stenosis, microstoma,
and contracted eye-socket are traceable to the same cause. Even to this date
the author has frequently to perform a second rhinoplasty upon patients who,
during a portion of their plastic career, proudly flaunted new and shapely noses,
which gradually diminished in size as a result of ulcerative processes within.

Mucous membrane is not often available except in the smaller mouth
defects, and the results of free mucosal grafts have been poor. Recourse,
therefore, is had to skin, either in the form of flaps or grafts. In its new and
moist condition of existence the surface epithelium appears macroscopically
to approach the mucosal type. In the nose, the formation of the mucosal
lining by swinging turbinatcs and septum into the desired position has been
successfully used on a number of occasions. When not available, an epithelial
lining is usually provided by means of cheek and bridge flaps turned skin in-
wards. If these flaps are not available, their place is taken by a Thiersch graft.
Similar type flaps from the margin of the defect or Thiersch grafts are used
in the rebuilding of the ocular aspect of new eyelids. In the smaller lesions
of the oral cavity, the new cheek or lip is lined by the advancement of mucous
flaps from the intact portions. Mucous membrane flaps are also used to replace

PRINCIPLES 9

losses of the vermilion border of the lips. When sewn over the raw edge of
the lip and thus exposed to the air, the buccal mucosa seems gradually to give
up the power of secreting without losing its colour, and a very natural appear-
ance is produced. In larger losses, the method of inturned skin flaps from
the neighbourhood is resorted to. It often happens that these flaps are hair-
bearing, a property which they retain in their new situation. The disability,
however, is not greatly complained of, and when excessive can be over-
come by dissecting off the hair-bearing layer later on, and Thiersch grafting.
The author has utilised non-hairy portions of forehead or of chest flaps turned
in as a lining for a buccal restoration. Several surgeons favour the grafting
of a separate flap of hairless epithelium on to the under-surface of the flap designed
to form the outside covering, before the latter is moved into position. This is
tedious, and a similar result can be more easily arrived at by the tube-pedicle
principle. Epilation by X-rays is unsatisfactory in the author's experience.
There is long delay. Permanent epilation is rarely obtained, and when
obtained the skin is avascular and atonic, and burns are liable to occur in
the process.

The fitting of an efficient denture upon a mandible robbed of its alveolar
ridge usually depends on the provision of a much-deepened labiogingival sulcus
to hold a flange of the appliance. Before the importance of lining the deepened
sulcus had been recognised, it was found impossible to prevent its gradual
obliteration by fibrous tissue. Now, thanks to development of the Esser inlay,
the sulcus can be permanently deepened in one small operation.

The Esser Epithelial Inlay. The provision of a lining for a deepened sulcus
was first carried out by Esser (vide Annals of Surgery, March 1917). He
inserted a moulded piece of dental composition wrapped round with a Thiersch
graft (deep surface outwards) into a pocket dissected out subjacent to the
mucosal lining of the existing sulcus, the whole operation being performed
through a skin incision. After a suitable interval the bottom of the sulcus
was incised, and the mould removed per oram, leaving the skin-lined cavity as
an extension of the sulcus.

The author having practised the typical Esser inlay with considerable
success and also extended its principles to the cure of ectropic conditions, it
occurred to his Dominion colleagues to simplify the method for providing a
lining membrane. Having discussed with the author the possibility of intro-
ducing the skin-graft per oram, Lieut. -Colonel C. W. Waldron, C.A.M.C., was
the first to perform this modification in this hospital. He was closely and
independently followed by Lieut.-Colonel H. P. Pickerill, O.B.E., N.Z.M.C.

Its obvious success led to great activity in the sectional dental departments
for its further improvement and simplification.

PLASTIC SURGERY

The details of the method are as follows :

A dental splint destined to control the Stent l is fitted to any existing teeth
or to the alveolar ridge (see figs. 1 and 2), and the sulcus is deepened per oram
to the satisfaction of the dental surgeon.

In this operation all scar tissue must be excised, and the knife must be
kept close to the bone, so that no loose soft tissues remain on the alveolar wall
of the sulcus.

An impression of the new sulcus is taken with warm Stent, which is made
to distend the cavity. When set, it is adjusted to the dental splint. It is

Fio. 1. Epithelial Inlay. (The arrows mark the limit of the skin graft.)

then taken out and completely covered with a large, thin, evenly cut Thicrsch
skin-graft, deep surface outward, and is pressed firmly into the rawed sulcus
and there maintained ten days by the splint. Meanwhile the dentist prepares
his appliance, and must be ready to fit it the moment the Stent is removed, as
the cavity is liable to shrink if left unoccupied for any length of time. As
an intermediary stage between the Stent and the final appliance, a mould of
black gutta-percha is sometimes used.

This operation may well be performed under regional anesthesia. The

1 The dental composition used for this purpose is that put forward by Stent, and a mould composed
of it is known us a " !Stent."

PRINCIPLES

I. The obliterated Sulcus.

2. Incision close to the bone.

3. Sulcus deepened.

4. Skin graft on Stent.

5. Graft on Stent in position.

7. Operation completed.

6. Cap splint with horizontal 8. Ten days later. Stent removed : Sulcus
adjustable flange. permanently deepened and lined.

Fio. 2. Stages in the Epithelial Inlay.

author is of opinion that the original method of Esser, difficult as it is, is still
the method of choice in a few rare cases.

A similar procedure has been successfully used in the nasal cavity, and for
lining the ocular aspect of a new eyelid.

12 PLASTIC SURGERY

The principle of the Esser Inlay marks an epoch in surgery, and the oppor-
tunities for its application are far from exhausted. A further modification
of it is discussed in this chapter in the pages devoted to " Coverings."

Supporting Structure. The importance of the general contour of the face
in the matter of expression is only realised gradually. Disappointment is in
store for him who would confine his repair to the surface tissues, heedless of
Nature's lessons in architecture. Theoretically, the application of one's ana-
tomical knowledge should suffice to point out the value of contour, but in
practice the realisation comes only by close co-operation with the sculptor.
In this matter of the general form of the part all sorts of artificial implantations
have been tried. Metallic plates and filigrees, celluloid plates, and injections
of liquid celluloid, solid pieces of wax, and injections of molten wax, have all
been used to build up the missing contour. Speaking generally, the use of any
foreign body is to be condemned whenever it is possible to substitute a graft
from the patient himself. Any form of a foreign body is a tissue irritant, and
tends to give trouble early qr late, in the attempt on the part of the tissues
to remove it ; whereas grafts, if successful in the early stages, continue satis-
factory. One celluloid plate which was used to replace a zygomatic prominence
developed over it a cold abscess five months after its implantation. The
healing had been primary, and when the abscess burst, the skin again healed
over the plate. But by far the greater number of celluloid plates had to be
removed within two months of their insertion.

Satisfactory early results are obtained by very cautious and repeated
injections of paraffin wax in small quantities, but the late results are rarely
good and are often appalling. It is not. suitable for the larger restorations,
and the imbedding of solid blocks of paraffin has not, in the author's experience,
been tolerated. The little experience the author has had with buried metallic
or vulcanite plates discourages further experiment with them. Professor
Mat-Bride, of the Imperial Research Laboratory, is at present carrying out a
research for the author on the implantation of celloidin into the ears of mice.

There is no royal road to the fashioning of the facial scaffold by artificial
means : the surgeon must tread the hard and narrow way of pure surgery.
Of the various autologous grafts available one has had enough experience to
form some conclusions. It may be laid down as a guiding maxim that the
replacement should be as nearly as possible in terms of the tissues lost, i.e.
bone for bone, cartilage for cartilage, fat for fat, etc. The use of bone-grafts
has been narrowed down to the replacement of mandibular and malar losses.

Cartilage for large cosmetic purposes stands unrivalled. It is available in
sufficient quantity, is easily fashioned to the desired shape, and, what is most
important, remains permanently in the shape and size in which it is imbedded,

PRINCIPLES 13

with the exception that if one perichondrial surface only is left, the graft tends
to bend, the perichondrium occupying the concavity ; and this property of
cartilage is utilised by the surgeon to obtain a curve in such positions as the
eyelids or the mandible. In cases of suppuration, there may be necrosis of
part of the cartilage and a corresponding secondary deformity may arise. This
is also the case when a part of the cartilage is left exposed in a mucous cavity.
The clinical evidence of the permanence of cartilage is borne out by the ex-
perimental work of Staige Davis (Annals of Surgery, 1917, vol. Ixvi, p. 88),
and by the histological work of Keith and Murray. (See figs. 3, 4, and 5, 6.)

The method of obtaining cartilage is a modification of that suggested by
Nelaton. A six-inch vertical incision is made over the costal cartilages having
its middle opposite the seventh, and is deepened through the rectus muscle,
which is widely retracted. The seventh, or the seventh and eighth cartilages,
are dissected free and removed with perichondrium intact, and are at once
transferred, wrapped in sterile gauze, to a table with three edges raised to prevent
disaster during the shaping of the graft. The wound is sutured by an assistant,
and the thorax strapped as for a fractured rib in order to avoid pain, which is
otherwise likely to be severe. Meanwhile, the surgeon shapes his graft with
a scalpel, leaving the perichondrium on one surface in cases where a curve or
a spring effect is desired. The graft is put into place and the wound sutured
without drainage, except in those cases where a lijematoma appears likely,
and any excess of cartilage is inserted under the skin of the upper abdomen
as a store for use in future operations, the pain of a further rib excision being
thus avoided. This hoard of cartilage may prove of use to others if not wholly
required by the patient himself. The question of homologous grafts opened
up by this procedure is of extreme interest, and a definite decision as to their
expediency has not yet been arrived at. It goes without saying that the donor
must be proved free from syphilis.

In this connection one had the opportunity of furnishing material from
various autologous and homologous cartilage grafts to Professor Keith. Dr.
J. Alexander Murray undertook this research for Professor Keith. Illustra-
tions (figs. 3 and 5) of two of his sections are given. Captain V- - and
Lieut. S were operated upon the same day. Some cartilage from
Captain V- - was put into the subcutaneous abdominal tissues of both Captain
V- - (autologous) and Lieut. S - (homologous). After eighteen months
the opportunity arose of removing these grafts. There is no doubt that in
both cases the cartilage is alive and active, but Dr. Murray finds that the cells
in the homologous (Lieut. S -) are more vacuolated and show more cal-
careous changes (i.e. degenerative) than do those of Captain V- . (See figs.
4 and 6.)

14 PLASTIC SURGERY

It should be noted that neither of these two grafts was submitted to stress
or strain in the region where it was buried. The author hopes that when
a cartilage graft is put under fairly normal conditions of functional existence,
such as is obtained when it is employed in nasal reconstruction, it will persist
in the form and position given it. Certainly, in the author's experience, no
changes other than curvature toward the perichondrial surface have occurred
in any of his successful autologous grafts, and in only a few of the homologous
grafts has the cartilage become replaced by fibrous tissue as a late sequel. Three
years is the longest that the author has had a graft under observation. Even
if partial calcification should occur this does not depose cartilage from its place
as facile princeps among facial supports.

The insertion of a cartilage graft may constitute a whole operation, as,
for instance, when it is introduced subcutaneously to elevate a depressed nasal
bridge ; or it may form a stage in a series of operations. In rhinoplasty (author's
method) the cartilage support for the nasal bridge is usually inserted subcu-
taneously under the skin over the glabella the skin destined for the lining
of the new nose and is swung down attached to the deep surface of this when
it is turned down at a later stage.

In the method suggested by Nelaton the support is swung down on the
deep surface of the flap designed to form the covering of the nose, a method
hampering free manipulation of the graft with a view to fixing it in the best
position.

It is sometimes convenient to employ yet a fourth method, in which the
support is built into its final position between the lining and the covering, before
the flap is raised. This procedure has been successfully followed in the replace-
ment of facial losses by pedicled chest-flaps. The part is fashioned upon the
chest by the manipulation of small skin-flaps, the cartilage graft being introduced
between two layers of a flap doubled upon itself, or between the flap and a
Thiersch covering of its under-surface.

When a softer contour is desired than would be provided by cartilage, local
fat and muscle flaps are used to fill the smaller hollows. The use of fat-flaps
is most satisfactory, and should be employed for all depressed scars. They
are discussed later in this chapter, and examples of their use are given in the
section on Cheeks. For larger hollows, free fat and muscle grafts are used ;
these are naturally more uncertain of result. All the author feels it possible
to say of fat-grafts is, that when successful, the result is very satisfactory, arc!
alteration of the contour from absorption has not occurred to any appreciable
extent while the case has been under observation. It is not yet established
lm\v they will be affected in conditions of wasting, or in old age. The fat-graft,
however, owing to fat necrosis, often undergoes a partial absorption, which is

PRINCIPLES

FIGS. 3 and 4. V. (Autologous graft.) No reaction at cut surface.
There is only a very shallow layer 1-2 cells deep of dead
cartilage cells. Under the old perichondrial surface the cells have remained healthy. In the
central parts of the cartilage the cells are arranged in small groups with deeply stained areas
of matrix around them very much the condition seen in normal adult costal cartilage. The
general matrix stains more faintly and is generally faintly fibrillated. This is not excessive.

-V... v

>->

FIGS. 5 and 0. V. rib. cart, in S. (Homologous graft.) The

cartilage cells are throughout more active, and occur not in -$

clumps, as in the donor, but in long columns towards "'*. .., ,*

the perichondrial surface isolated cells of spindle form are

most numerous. In the deeper parts rounded groups with

darkly-stained secondary capsules occur also. Fibrillation of the general matrix is fairly frequent,

but not excessive. It looks as if the graft in the strange soil had proliferated more actively, and

was still remote from the quiescent stage which is seen in the autologous graft.

16 PLASTIC SURGERY

carried to greater lengths if the products of this disintegration become infected ;
but even in this latter unfortunate event not all the fat (or muscle) comes away,
and eventually there is left sufficient substance to aid very materially in any
future work on the part. Fat-grafts are frequently recommended as a pre-
liminary to a bone-graft, and, in the author's opinion, rightly so.

Of other ways of building up the facial contour, the author would like to
draw attention to the following, which are available only in certain localities.
The malar prominence may be simulated satisfactorily by the svibcutaneous
advancement of the adjacent temporal muscle, as described on p. 55. In
partial or complete rhinoplasty, considerable help is sometimes obtained in
building up the sides or bridge of the nose by the use of turbinate grafts and
muco-cartilaginous flaps from the septum, before the skin covering is applied.

With regard to anterior palatal perforations involving loss of the premaxilla,
it is not the author's practice to attempt a purely surgical repair. The goal
of obtaining efficient mastication is more certainly achieved by a mechanical
repair at the hands of the dental surgeon.

The Covering Tissues. In the provision of a covering there is little choice
in the way of material : one has to decide between using a skin-flap or one of
the types of skin-graft.

Generally speaking, the application of skin-grafts is limited to superficial
lesions. Where a gap is to be bridged, or where tension is likely to occur, a
skin-flap is indicated.

Skin-grafts. The preparation and manipulation of the various forms of
skin-grafts with a nice judgment in their use constitute an important part of
the plastic surgeon's stock-in-trade.

(1) Thiersch grafts. In plastic work the simple Thiersch graft is not of
very wide application, but in specialised forms its use covers a very wide range.
The Esser Inlay has been already fully described. The author has adapted
the Esser inlay to surface use in the method known as the " Epithelial Outlay,"
which finds its most important application in his operation for the relief of
ectropion of the lids, as follows : An incision is made, skirting the lid edge,
and the lid liberated by dissecting freely till closure can be effected without
tension. In the resulting cavity is buried a closely fitting Stent mould covered
with a Thiersch graft, over which the edges of the incision are sewn with horse-
hair, the sutures taking up the edges of the skin-graft. After some eight days
the Stent either falls out or is removed, and the lid falls easily into position.
See section on Burns, pp. 376-7, and fig. 7.

The principle is applicable in many other localities, notably in cases of
adhesions between the pinna and the scalp following burns.

(2) H'olje and W hole-thickness gmJts.~T\\e factors determining the successful

PRINCIPLES

use of these grafts are somewhat obscure, but it may be laid down that firm
apposition and accurate coaptation of the edges are essential. It would seem
also that tension assists tension of a degree comparable with that obtaining
in the area from which the graft is taken. Apposition is most easily achieved
and maintained when bone or cartilage closely underlies the area to be covered,

IMCiSION,
JUST ABOVE CiLiflRY BORDER

SCM CRAFT IN POSITION
SHOWING SUTURES THROUGH
EYELID *f(D TMIERSCM GRAFT

UPPER ADD LOWER EDGES OF
IMCISIOM SUTURED OVER STEMT

INCISION ALONG LINE OF 3UTURE5

EYELID LOWERED SHOWING
OUTLINE OF TMIEA5CM CRAFT

FIG. 7. Stages in the Epithelial Outlay Operation.

as in the forehead or nose ; and it is only in such regions that immobility
obviously a desirable factor is obtainable.

The fact that a large graft is less likely to take in its entirety than is a
small one is improbably due to any inherent disability in the question of size ;
it is very possibly explained by the fact that the above-mentioned factors are
more difficult of attainment in a large graft.

18 PLASTIC SURGERY

These grafts are in routine use for covering raw areas upon the forehead
left by the removal of rhinoplastic flaps, and for providing a healthy covering
for the nose in cases of severe facial burns. For small areas the skin may be
taken from the back of the neck ; for areas up to two inches in diameter the
skin is taken from over the biceps the conditions of tension in this region
being suitable. Larger grafts are taken from the chest or abdomen.

The question as to whether the graft shall be skin-deep or contain a layer
of fat is determined by the needs of the case, there being no marked disparity
between the two in the matter of viability. If hair is required the scalp in
the post-auricular region is employed ; the author has successfully used whole-
thickness grafts from this region in the replacement of eyebrows lost through
burns. (Case No. 338, p. 356.) The details of the method employed in a typical
case may be of interest ; the example taken is the grafting of the raw area on
the forehead after a rhinoplasty, where the returned pedicle is inadequate wholly
to cover the defect.

By the time the pedicle is returned the area is covered by healthy granu-
lations. It is customary to scrape these away, as in cases where they have
been left the patients have complained of a feeling of constriction round the
head, presumably caused by the contraction of this large mass of scar tissue.
The area to be covered is accurately mapped out with tinfoil, and the foil outlined
upon the chest or upper arm with the point of the knife. The graft is then
dissected up, care being exercised to avoid bruising it with forceps. It shrinks
greatly as it is freed. If the bone is exposed on the forehead, the graft is cut
so as to contain a layer of fat, for though a graft will often take upon bare bone
it is liable to adhere too closely for normal movement unless fat intervenes.
Fixation sutures are now inserted at the corners of the graft, so as to ensure
symmetrical tension, and accurate coaptation of the edges is then effected with
continuous horsehair sutures. Meanwhile, an assistant has prepared a Stent-
backing to the tinfoil map of the area, and this is firmly pressed into the
slight depression now occupied by the graft while still in a semi-solid condition,
and the whole firmly bandaged to the head. The pressure is maintained for
about forty-eight hours, and the graft then observed. If the prognosis is
favourable, it will by this time have assumed a somewhat forbidding livid and
mottled appearance, and will have swelled considerably. Any portions that
have died will appear white and opaque, or black (underiun by clot). Stitches
are removed about the fifth day, and massage is applied after about three weeks.

Skin-flaps. The delineation and manipulation of skin-flaps constitute
the ABC of the plastic surgeon's metier. The subject has been worn threadbare
in countless textbooks, and it is not proposed here to give a compendium of all
possible flaps.

PRINCIPLES

Essentially, all flaps are similar, and consist of two parts the part chiefly
concerned with the traffic in circulatory fluids, and the part available for plastic
use.

Broadly speaking, flaps may be grouped as follows :

A. Advancing flaps.

B. Transposed flaps.

The differences are portrayed in the following diagrams illustrating their
use, the pages devoted thereto being intended as part of a glossary for terms
used later in the book.

The majority of the terms used are self-explanatory. " Ascending "
flaps are those in which the skin from below the defect is swung up on a base
roughly on the same level as the defect. Thus, an " ascending neck-flap " is
one the body of which has been raised from the neck, the base being, for instance,
on the lateral aspect of the chin.

In actual use, modifications of these flaps are employed according to the
locality ; thus, for rhinoplasty, instead of the traditional forehead bridge flap,
the author is now employing a long flap containing the anterior branch of the
superficial temporal artery, based on the pre-auricular region. The middle
portion of the flap is " tubed " (see figs. p. 21), and when severed from the plastic
portion after some ten days, is opened out and replaced upon the forehead,
leaving a raw area no larger than that left by the Indian method. The blood-
supply of this flap is remarkable ; its nourishing vessel spouts freely when the
tubed portion is severed from the new nose.

The transposed flap (imbedded type) is usually employed about the eyes
and mouth, a depression of the buccal orifice being relieved by transposing a
flap from the corresponding naso-labial fold to a position below the orifice, the
flap in this case being a " descending naso-labial flap." If the tissue in the
naso-labial fold is scarred or otherwise unsuitable, an ascending neck-flap can be
employed to produce, in a less degree, a similar result. But in this case the
flap must be taken from the side of the neck, being swung through ninety degrees
from a vertical to a horizontal position ; otherwise the gain of skin below the

Fio. 8. Flaps.
A. ADVANCING FLAPS
1. SIMPLE ADVANCEMENT (Forward type).

Defects.

Incisions and Excision.

Flap A. Advancing.

Suture.

PLASTIC SURGERY

2. " V. Y. 1 ' ADVANCEMENT.

A-

.A'

Defect. Incision. Suture.

3. SWINGING ADVANCEMENT (Combination of Forward and Lateral Advancement).

Defect.

Incision.

Suture.

B. TRANSPOSED FLAPS

1. IMBEDDED.

Defect.

2. BRIDGE FLAPS.

(a) Si m pl e Pedicle.

Incision.

""^ A

Suture.

Eyebrows lacking.

Incisions.

Suture.

PRINCIPLES

(6) With Pedicle "tubed." (Author's Method.)

^ L

Detect.

Flap Pedicle " tubed."

Flap swinging upon Pedicle.

Suture.

Pedicle being returned and unrolled.

PLASTIC SURGERY

mouth has to be written off against the loss which occurs when the bed from
which it was raised is closed.

The use of flaps is not confined wholly to the provision of a skin covering.
In many cases the flap is used as a vehicle for the introduction of a cartilaginous
support previously imbedded in it, as discussed earlier in this chapter. A
typical example occurs in the reconstruction of the nose, in which the bridge
support a cartilage rod is imbedded under the skin destined to form the
lining of the vestibule, and swung down upon its deep surface to occupy a position
between the lining and the covering. (Figs. 388 and 389.) A similar principle
has been employed in the reconstruction of the chin in a chest-flap previous
to its elevation.

The plastic surgeon must early acquire an instinct for forecasting the
viability of the flaps he uses. Apart from those containing a definite artery
such as the superficial temporal (the base for which may be cut quite narrow),
generally speaking the base should be at least as wide as any other part of the
flap. The length which may be safely taken varies with the breadth and depth
-particularly the depth. If the depth includes no more than the true skin, it
seems in practice safer to use a graft than a flap : a skin-deep flap of any length
is found rapidly to become cedematous, and often dies from the obstruction
thus caused. The explanation perhaps lies in the fact that egress for the products
of metabolism is inadequate. In the early stages of a free graft the ebb and
the flow of tissue-fluids are conditioned by the same factor, the osmosis resulting
from the biochemical activity of the cells : the matter is not complicated by
the continued arrival of fluid from without, and marked congestion does not
arise.

In the event of oedema of an intensity likely to jeopardise the life of the
flap, it has been taught that multiple punctures are indicated. The author
prefers gentle efferent massage, which avoids the creation of minute thrombi
and of extra channels of infection, and which helps to dissipate the commencing
lymphatic and venous stasis. Furthermore, hot moist dressings have a definite
effect in helping the sluggish corpuscle back to the normal circulation. It is
the author's opinion that in a flap thrombosis may be caused by merely a few
minutes' pressure, as from a kink.

The viability of flaps varies greatly in different regions. Those based
about the chin are never a cause of anxiety, whereas ascending flaps from the
neck contain the possibilities of disaster and must be treated with the greatest
respect. It is of advantage, when dealing with a flap whose chances of life are
precarious, to wrap it with a hot saline pad during the ligature of arteries, etc.
It goes without saying that in cutting a flap one should, if possible, avoid its
containing scar tissue : in the altered condition of existence the scar is liable

PRINCIPLES 23

to swell, not only forming ah unsightly blemish but being highly prejudicial
to the blood supply.

Among other conditions which are prone to affect the viability of a flap,
the surface to which it is applied exercises a most powerful influence. It has
been observed that flaps containing scar tissue which would certainly die if im-
planted upon the face, will often live upon the same base if applied to form the
lining of a mucous cavity, where warmth and moisture are present.

In this question of viability of flaps the personal equation of the patient
and of the surgeon comes strongly to the fore.

ANESTHESIA (CAPTAIN WADE)

The administration of anaesthetics for the plastic surgeon is a highly special-
ised procedure.

To begin with, the majority of plastic operations are unavoidably long ;

tthe insertion of sutures alone is apt to occupy a skilled surgeon more than half
an hour. The type of patient, too, is often unfavourable, especially in cases
of wounds involving the oral cavity, where a long convalescence has been
hampered by ill nourishment.

Moreover, the airway, in many cases, is strangely distorted in some part
of its course ; and, in addition, the surgeon must perforce trespass upon the
territory usually regarded by the anaesthetist as his own.

Evidently, therefore, there is scope for any and every device that will
diminish effort for the patient and the anaesthetist, and bring the prolonged
strain within the limits of endurance.

An arrangement must be come to also by which the surgeon is spared the
disability of disputing the possession of the parts.

For large operations upon the mouth region, intra-tracheal administration
in some form has been adopted as a routine. Where the form of the parts
permits, a catheter is introduced into the trachea through a Mosher's laryngeal
speculum under the guidance of vision. This may be prevented by the pro-
jection of splints fitted to the upper jaw, or by conditions of microstoma, trismus,
contracted mandibular arch, etc., in which case intra-tracheal anaesthesia is
effected by means of a laryngotomy, or, in rare instances, a tracheotomy. Ether
t is the intra-tracheal anaesthetic of choice. It is given under positive pressure,
being carried either by a stream of oxygen from a large cylinder or by a stream
of air propelled by a small electrically driven motor, either way leaving the
anaesthetist the use of both his hands for the manipulation of the stop-cocks, etc.

In smaller operations upon the mouth, it is found convenient to use a nasal

_u PLASTIC SURGERY

tube or tubes, the pharynx being shut off by plugging the hinder portion of the
buccal cavity with loose gauze which is renewed from time to time.

When the operation is upon the nose, the nose and post-nasal space are
plugged, and a Hewitt's airway is employed.

In all these cases, the anaesthetic is conveyed through a tube long enough
to avoid interference with the surgeon, the means of propulsion being as in
the intra-tracheal method.

Administration by positive pressure undoubtedly relieves the patient of
much of the strain of a long operation, and the ease with which pure oxygen
or air can be substituted for anaesthetic through the clear airway achieved by
the methods described, diminishes the stress associated with cyanosis to a
minimum. The difficulties consequent upon the routine adoption of these
methods are easily overcome with practice. The anaesthetist must learn to
depend almost solely on the respiratory movements and the pulse as his guide,
with rare peeps at the pupil.

I propose here to discuss some of our methods in more detail :

Chloroform and Oxygen in the Sitting-up Position. This method was intro-
duced to us by Colonel J. F. W. Silk, Consultant Anaesthetist to the War Office,
in September 1916. It is most suitable for upper lip operations with or
without loss of continuity in the maxilla. It is also useful for those cases
of extensive loss in the mandible where the fragments cannot be held by
suitable splints. The advantages of the method are, firstly, that the blood
flows forward out of the mouth ; secondly, there is less bleeding ; thirdly, the
surgeon has a very good view of the patient's face. But it is certainly a tiring
position in which to operate.

In my experience, with healthy men it is a safe form of anaesthesia. In
200 cases I have never had to alter the position during the early stages. Very
occasionally they become faint towards the end of long operations and have
to be lowered to the horizontal, where they quickly recover. A very light anaes-
thesia is required after the first half-hour. In some cases they pass into a stage
of analgesia, during which they will answer remarks quite sensibly for half an
hour or more before the operation is finished.

Technique. One end of the operating-table must be capable of being raised
to the perpendicular, and must be long enough to reach to the patient's shoulders
in this position. A suitable head-rest must also be attached. Induction is
carried out in the sitting position, the back of the table being raised to just
short of the perpendicular. When induction is completed the head is bound
firmly to the head-rest. The position of the head is important ; if it leans too
far back blood will flow into the fauces, if too far forward the airway may be
obstructed. It is sometimes easier to get the best position by adjusting the

PRINCIPLES 25

trunk to the head. When this is satisfactory, and the patient is breathing easily,
a No. 10 rubber catheter is passed down one nostril to the pharynx. The
catheter is connected by a suitable length of rubber tubing to a Shipway's warm
ether and chloroform apparatus, to which an oxygen cylinder has been attached,
and the oxygen made to pass through the chloroform bottle at the required
rate. The oxygen should always be turned on before the rubber tube from
the catheter is connected to the apparatus. As a rule, this is a very convenient
method for the anaesthetist, but occasionally the jaw requires support. If
anaesthesia becomes deeper than the operation requires, the oxygen rate can
be slowed or the rubber tube from the catheter disconnected from the apparatus
for a time, or connected direct to the oxygen if necessary.

The Nasal Tube. This was described by my colleague, Captain J. C. Clayton,
in the Lancet.

I always use the largest tube (size 20) which it is possible to pass down a
nostril. If the tube is cut to a blunt point it will be found to pass more easily.
If there is difficulty in passing one of the required size, it is better to pass a
smaller one first, leave it in place a few seconds, and then try the larger one
again ; in most cases this can now be passed easily.

One of the objections to this method is that the tube is liable to kink at
the level of the ala. I have overcome this by cutting the nasal tube short at
the ala, and inserting into it one end of a right-angled metal connection of the
same bore as the tube. The other end of the metal connection is joined directly
to the funnel-end of a Kahn's tube by a short length of rubber tubing.

This arrangement has two advantages : firstly, it provides a shorter length
of tubing for the patient to breathe through ; and, secondly, the Kahn's tube,
being metal, cannot be inadvertently compressed by the surgeon, and thus
a clear airway is assured, always provided that the end of the tube is in its
proper place just above the epiglottis and that the tube is not flattened too
much in its passage through the nose.

The mouth and pharynx are then loosely packed with gauze so as not to
compress the tube. The operation should not be commenced till the patient
is breathing comfortably. Anaesthesia can be maintained, either by dropping
chloroform on to a layer of house-flannel stretched over the funnel, or by blowing
a warm ether or chloroform and ether into the funnel from a Shipway apparatus.

In some cases where the airway is just not sufficient there may be some
cyanosis. This can be corrected by giving oxygen when necessary. It is very
often necessary to support the jaw.

This method is very useful for lip plastics, provided that the tube is not
in the surgeon's way ; and for epithelial inlays and cleft palate operations.

In the last-named I prefer to give chloroform or chloroform and ether

26 PLASTIC SURGERY

from a Shipway apparatus, through a catheter passed down the nose to the
pharynx. The patient's shoulders are raised and the head fully extended. In
this position it is impossible for the blood to enter the larynx. The difficulty
is to keep the patient from coughing. This can be avoided by resting the little
finger of the hand holding up the jaw on the larynx when any swallowing move-
ment the prelude to a cough is at once appreciated.

The choice between this and the sitting-up position, provided the patient
is healthy, rests entirely with the surgeon.

In operations for reconstructing the chin or lower lip, where there is ex-
tensive loss of the mandible and the fragments are not controlled by splints,
there is no support for the base of the tongue, and it is very difficult to maintain
a clear airway. Laryngotomy or tracheotomy is the simplest way out of the
difficulty, but there are two possible objections to employing either. The
patient will probably require more than one operation or the surgeon may
wish to take a flap from the neck. I have only employed laryngotomy once
in these cases, and have found one or other of the following methods satisfactory.

(1) Chloroform and oxygen, in the sitting-up position, with the head
slightly extended.

(2) Kahn's tube. At one time this was used very frequently, but we gave
it up because of the difficulty of being certain whether it was in the larynx or
not. The following two cases were very interesting with regard to this
point :

The first was a bone-graft where the jaws could not be splinted. I had
a great deal of trouble with the airway, and as a last resort introduced a Kahn's
tube. The head was lying on the left side and covered up with towels. It
was most unlikely that the tube entered the larynx, but the patient at once
breathed perfectly easily through it.

The second was a chin plastic. After a perfectly quiet anaesthetic through
the Kahn's tube, the patient vomited at the end of the operation before the
tube had been removed, and he vomited entirely through the tube, nothing
coming into his mouth past it.

If the tube is in the larynx the anaesthesia is very good indeed, and in
these cases it is often possible to reach the larynx with the finger and be certain
that it is in position. If it is not in the larynx, it may still be serviceable, but
there may be trouble during the operation. I have never seen shock during
or following its use, even in operations lasting as long as four hours.

(3) A good airway may also be obtained by placing a small pillow under
the patient's shoulders, extending the head, and at the same time making traction
on the tongue.

Chloroform and oxygen can be supplied through a catheter passed down

PRINCIPLES 27

the nose. If the surgeon objects to the tongue being drawn out it can be levered
forward by a sponge-holder, the upper teeth being used as the fulcrum.

Operations on the Nose. For short operations (under two hours) anaesthesia
may be maintained as follows :

After induction a silk stitch is passed through the tongue and a post-nasal
plug introduced if necessary. A very convenient retractor for the soft palate
can be formed by obtaining an ordinary copper retractor half an inch wide,
and bending the last inch to a right angle. This can easily be slipped behind
the palate, and takes up much less room than the finger. The swab is then
introduced digitally, or with Luc's forceps. A Hewitt's airway is placed in
the mouth ; the end of a short and suitably bent metal tube, about | in. in
diameter, is placed just inside the mouth of the Hewitt's airway, and the other
end connected by a rubber tube to a Shipway's warm ether apparatus. It
must be remembered that this tube must not be too long or the vapour will
have cooled by the time it reaches the patient. This apparatus is very econo-
mical, and has the additional advantage of enabling the anaesthetist to maintain
a very uniform anaesthesia. I have found that, using a mixture of chloroform
and ether, one compression of the bulb to every third inspiration is sufficient
to keep the majority of these men under.

If a constant stream of air or oxygen is passed through the apparatus
there is loss of heat and waste of anaesthetic during expiration.

In long operations (over two hours), such as rhinoplasty, including, as a
rule, the removal of a piece of costal cartilage, we were at one time accustomed
to employ oil-ether anaesthesia, because of the lower incidence of post-anaesthetic
vomiting with this method. This is especially important in rib cases on account
of the pain.

In properly selected cases this is a very uniform and safe anaesthesia. During
a personal experience of over 200 cases I have only been unduly anxious about
one patient during the operation, and that was before I gave up using hyoscine
in the preliminary hypodermic. This method should never be used if blood
is likely to enter the air-passages, for bleeding may continue after the patient
leaves the theatre, and, as they usually take a long time to come round, there
is grave risk of blood entering the trachea.

It should not be employed if there is an obstructed airway e.g. loss in
lower jaw without fixation, unless the anaesthetist is prepared to stay with the
patient from the time the oil-ether is run into the rectum until the patient is
thoroughly round from the anaesthetic. Complete rhinoplasty involves little risk
of post-operative bleeding, and I have rarely seen any trouble in these cases.

The post-nasal plug, if required for the operation, should be left in situ
until the patient has recovered from the anaesthetic.

28 PLASTIC SURGERY

I prefer the paraldehyde mixture ; ether 5 oz., paraldehyde 2 drams, olive
oil 2 oz., but the paraldehyde causes excessive sweating in some patients. Dose :
It is difficult to form any fixed plan. Some men go under quite quickly, whereas
others of the same weight require a great deal more anaesthetic for induction.
We have been very much handicapped by being unable to obtain olive-oil,
and the results have been much more uniform since it has been on the market
again.

In cases in which blood is not likely to enter the airway (except in cases
where the jaws are splinted together), anaesthesia may be maintained by means
of a Shipway's warm ether apparatus, with a Hewitt's airway in the mouth, as
described above under " Short Nose Operations."

Bone-grafts of the Mandible. As the jaws are splinted in the closed-bite
position intra-tracheal administration is out of the question.

For a long time we gave oil-ether anaesthesia for these, with good results.
The tongue is held forward by the splinted lower jaw and does not fall back.
It is better to ensure free nose breathing by introducing a nasal tube Additional
anaesthesia may be given either through this or through a bent metal tube placed
in the mouth. As an alternative, a general anaesthetic may be given through
a nasal tube as described above, under " Operations involving the Mouth."
During the last six months we have given up oil-ether anaesthesia for these cases
and have employed chloroform and oxygen through a nasal tube with satisfactory
results, and I think it is to be preferred, both on account of the lessened risk
of pneumonia, and the quick recovery from the anaesthetic.

In this class of surgery there should be more than usual co-operation between
the surgeon and the anaesthetist, both in regard to watchfulness over the patient's
condition and in manipulations involving the airway.

R. WADE.

OPERATION

The general technique of a plastic operation differs slightly from that used
in general surgery, in that the question of the ultimate appearance of the area
of operation occupies a much more important place. The slightest insult to
the skin of the face is in some subjects visibly recorded in scar tissue, especially
where the blood-supply is poor from any reason, such as tension or the presence
of scar tissue ; and it is therefore bad practice to use tissue forceps upon the
skin edges, the grip being properly taken on the deep surface. The production
of an invisible scar is a question constantly exercising the mind of the plastic
surgeon.

A few points are given below descriptive of the author's usual practice
with regard to general technique which may prove of interest.

PRINCIPLES 29

The skin of the patient is usually prepared at the time of operation by firm
wiping of the parts with an ether swab. This removes saprophytes on the surface
without damaging the epithelium. This is usually followed by a light coating
of iodine, applied once only. In cases where the epithelium is tender, as in
burnt cases, the ether is followed by methylated spirit, the iodine being omitted.
It is also possible that iodine is an unsuitable preparation for skins that have
previously been the seat of erysipelas. Similarly, in young subjects and in
women where the epithelium is delicate, the iodine is omitted. The same
holds good in the preparation of areas from which skin-grafts, either Thiersch
or Wolfe, are to be removed. For Thiersch grafts, very vigorous rubbing with
ether is practised until the whole area glows.

The general care of the patient with regard to fatigue, shock, and haemorrhage
must be borne in mind, just as in other branches of surgery. The treatment,
actual and preventive, has no features peculiar to this branch of surgery. A
special note of warning, however, will not be out of place in regard to the in-
halation of blood and mucus, which will further decrease an airway often already
insufficient, and will greatly add to the patient's fatigue in these lengthy opera-
tions. The amount of shock produced by an operation depends, among other
things, upon the area of disturbed skin surface. This is particularly noticeable
when large chest skin-flaps are used for the face.

Needless to say, the general and local condition must be the best possible
before a major plastic operation can be undertaken. The original wound
must have healed soundly, the condition of the upper respiratory passages and
accessory sinuses must be above suspicion, and the skin must be free from pimples,
acne pustules, and the like. In many cases certain preliminaries will have been
completed, such as the excision of exuberant scars, or non-operative treatment
to soften keloidal tissue and improve the blood-supply.

Stages. Most of our operations consist of two or more stages. The use
of bridge-flaps necessitates a second operation for the return of the pedicle,
but this does not always need a general anaesthetic. The pedicle is returned
not earlier than ten days in most cases, and it is of advantage largely to increase
this interval where the blood-supply of the receiving bed is dubious. The
returned pedicle covers most of the bare area from which the flap was taken,
and the remainder is covered either by undercutting and advancing the margins,
or by a Wolfe or whole-thickness graft. The graft, after being sutured, should
be pressed firmly into place and held there by a pad of gauze or a Stent mould
firmly bandaged to the head. The most frequent cause of failure of a Wolfe
graft is lack of pressure firm enough to ensure complete apposition. Apart
from the return of pedicles, our operations are frequently designed in stages ;
for instance, in rhinoplasty the normal portions of the tip and alse have frequently

30 PLASTIC SURGERY

to be released from scar tissue and restored to their normal positions at a stage
prior to the remaking. At this stage also the blood-supply of the prospective
inturned flaps is secured by attaching their future base to the rich blood-supply
of the nasal mucosa. Similarly, in large facial replacements for burns, the
blood-supply of the flaps is rendered more secure by the preliminary tubing
of the pedicles. Countless other examples of the necessity of dividing the
restoration into stages will spring to the mind of the reader.

The simplest operation in plastic work is the excision of scars. This is
important, not only from the cosmetic point of view. Apart from actual loss,

1. Depressed scar.

2. Incisions for excision of scar
and delimitation of fat flap.

3. Fat flap swinging. 4. Flap fixed under new scar.

A. FAT FLAP BASED ON DEEP FASCIA.

JL 1

1. Depressed scar. 2. Incisions. 3. Suture.

B. FAT FLAP BASED ON THE SKIN.
FlO. 9. Showing use of subcutaneous fat flaps. (Sectional view.)

no factor so impedes function as does scar tissue, whether by hampering mobility
or by constriction of tubular organs, such as blood vessels and ducts.
The general aims in scar excision are :

1. Liberation of fettered tissue.

2. Restoration of contour.

In either case it is essential that all the scar be excised. It is remarkable
to what extent a deformity will recur if only a small amount of scar escapes.

In unfavourable subjects it may be that the scar must be excised a second
or even a third time before a presentable appearance is effected.

The restoration of contour is aided by the subcutaneous rolling in of fat-
flaps, as indicated in the accompanying diagrams. In most cases the flap is

PRINCIPLES

based on the deep fascia (fig. 9 A : 1 to 4), the skin being undercut till the desired
area of fat is exposed, after which the knife is carried deeper till the flap can be
drawn across and sutured in its new position. In another method (Aymard)
the flap is based upon the overlying skin. This is more difficult of execution,
as the knife is invisible during the delimitation of the flap, but it is the method
of choice on occasion, especially in the malar region.

Suture. The insertion of sutures occupies about half the time taken by
one of these long operations. Sewing up after a total rhinoplasty takes almost .1,
one hour even in experienced hands : so that dexterity and smooth technique 9

Fio. 10. Author's instrument.

in this particular are of outstanding importance for the sake of the patient.
The " No Touch " technique is fortunately compatible with this desideratum ;
it is found that, with practice, stitches can be tied very rapidly with forceps,
especially with the author's instrument depicted above. This instrument also
embodies the property of scissors, and further saves time by allowing the surgeon
to cut his own sutures.

The material usually employed for the apposing layer is horsehair ; its
elasticity is of great importance in allowing a nice adjustment of the edges,

PLASTIC SURGERY

especially when employed in continuous suture, as is very often the case. In-
terrupted sutures are first inserted at corners and other guiding points, and the
continuous suture is carried right past them. A trial is now being made of
" Japanese Silkworm Gut," a material of great elasticity, the strength of which,
in proportion to its calibre, is even greater than that of horsehair. Retaining
sutures are of silkworm gut.

The use of subcuticular sutures for the closure of facial wounds would at
first sight seem to be ideal ; and, under certain conditions, this is the case. A
long, straight incision, all portions of which are in the same plane, is best closed
by this means. But where an incision is irregular or passes over an alteration
of contour, the avoidance of " bunching " is so difficult with a subcuticular
suture that a good scar is more likely to result by other means.

Subcutaneous sutures are of great value as retaining sutures. The author
uses a modification of the " near-far far-near " suture to subserve the double
purpose of retention and apposition as indicated in fig. 11, which prevents in-
version of the edges.

SECTIOMflL VIE1W

THt SUTURE
IN POSITION

FIG. 11. Subcutaneous near-far far-near suture.

The material employed for subcuticular apposing sutures is usually horse-
hair. Catgut is found to produce a heaped-up edge, and linen thread has, on
more than one occasion, proved itself to be an irritant.

Catgut is the material of choice for subcutaneous retention sutures, chromic
gut not being well tolerated in the face.

Invisible Scars. The author has devoted much time and thought to the

PRINCIPLES 33

production of the optimum scar. It actually happens on occasion that a facial
scar is for practical purposes invisible, but one must admit that the factors for
ensuring such a desirable result are not always to hand.

The factors necessary for the production of the optimum scar are :

(1) Asepsis.

(2) Avoidance of tension on the apposing sutures.

(3) Perfect apposition of the skin edges.

(4) An often unknown personal factor in the patient.

(5) Early removal of sutures.

The avoidance of tension on the edges is found to be a factor of extreme
importance : one often sees a transposed flap, the scar delimiting one edge of
Avhich is clearly visible, while that along the other edge is almost invisible, the
difference being due to the fact that there is inevitably more tension on the edge
along the long or convex side. To avoid tension on the edges it is customary
to insert deep retaining sutures wide of the incision, the ends being, if necessary,
guarded by buttons to distribute the pressure. The apposing sutures should
be inserted very close to the edges, and may be at very close interval if that
is thought necessary to ensure a critical closure. Apposition is occasionally
assisted by the insertion of a few everting mattress sutures about 3 mm. from
the edge. With a view to ultimate invisibility of scar some surgeons make
their incisions with the plane of the blade at an oblique angle with the surface,
so that Avhen the wound is closed there is a slight overlapping of one edge by
the other.

VLR.TICflL INCISION

OBLIQUE.

FIG. 12. Incisions.

The author has not found that this method on the whole leads to a more
perfect scar.

It is found that invisible scars more often occur in patients whose skins
are ruddy and beset with small venules. Skin-flaps on such subjects are wont
to acquire a florid habit, and their edges soon fade into their surroundings, the
scars becoming permeated with the tiny vessels.

Dressings. Dressings are but seldom required upon the face. Where a

34 PLASTIC SURGERY

wound has been closed with drainage an appropriate covering is naturally applied,
and it is customary in the case of grafts to provide some means of maintaining
firm apposition ; but for the most part the face is left exposed to the air. Where
it has been necessary to use a flap of precarious viability, hot saline packs are
applied at the close of the operation and are renewed two-hourly, with excellent
results.

AFTER-TREATMENT

Apposing sutures are removed on the third or fourth day, retaining sutures
being left till their function is fulfilled. Thus, it is the author's custom at the
conclusion of a rhinoplasty, to insert one or more horsehair stitches transversely
through the new nose, and tie them so as to produce a narrowing of the organ
at certain spots. These are left till they have caused a certain amount of in-
flammation, so that the scar-tissue which ensues will take over their function
permanently.

Massage is of great use in dispersing the oedema which often arises as a
temporary disability in newly made flaps, and is indicated as a routine measure
for assisting in the restoration of function.

The closest watch is maintained during the first forty-eight hours upon the
site of operation, especially where a new or doubtful flap has been employed.
Even in well-tried flaps cedema may occur, and lead to disaster unless promptly
dealt with.

Electrical treatment in the form of vibro-massage for bone lesions, diathermy,
ionisation, X and other rays, is part of the routine after-treatment, as in other
branches of restorative surgery.

A trial is being made at present of the application of a rhythmic sinusoidal
current as an aid to osteogenesis in mandibular bone-grafts. (Barclay.)

Early active movements are encouraged, generally speaking ; and this
principle is applied to mandibular bone grafts where the gap is inconsiderable.

In conclusion, it may be said that Time is the plastic surgeon's greatest
ally, and at the same time his most trenchant critic.

REPAIR OF THE CHEEK

CHAPTER II
REPAIR OF THE CHEEK

IN discussing in detail the experience in the repair of the various sections,
it is not possible to confine each case and its method of repair within
exact categories ; but as far as possible I have divided the face into regions,
and each region into groups, as judged by the extent of the destruction. In
each group the methods of repair used are set forth and the results criticised,
while examples of cases and methods are interspersed in the reading matter,
so that reasons for many statements may be supported by illustrations of
actual cases. Many of these cheek injuries secondarily involve the lower eyelid,
the nose, or the mouth ; but the following cases, though thus complicated, have
their main interest centred in the cheek repair. Owing, however, to the obvious
overlapping of the injury from one to other regions, cross references will fre-
quently be made to the part of the book where the illustration is to be found.
Thus, Case 70, in the chapter on noses, shows a very severe cheek injury, but
as the interest of the repair, to my mind, is centred in the smaller nasal part
of the injury, it is not separately described in the present chapter.

The cheek is an area of plastic surgery which lends itself to good results.
The lining membrane is not usually a stumbling-block, as in lip and nose work.
The supporting structure, when not supplied by a dental prosthesis, is found in
a bone graft for the mandible, cartilage for the superior maxilla, and muscle or
cartilage for the malar-zygomatic prominence. The skin covering, when not
available locally, is made good by flaps from the whole neck area or from the
temporal region.

I have arbitrarily divided this region into :

(a) Depressed scars.
(6) Loss of soft tissues only.

(1) Malar Prominence.

(2) Superior Maxilla Alveolus, Antral Wall, Infra-orbital

Plate.

(3) Mandible.

(a) DEPRESSED SCARS

Depressed scars may be defined as those associated with such small losses
of tissue that the majority of them may be repaired by excision of the scar,
under-cutting the skin and approximation, without the necessity of cutting
flaps.

38 PLASTIC SURGERY

They are usually the result of the exit of a bullet, of the glancing blow of
a fragment, or of the entrance of a small shell or bomb fragment. The scar
produced by an exit wound is stellate, while that of an entrance wound,
though it may be irregular, is usually concentrated in the middle of the
depression. Of the two kinds, the radiating scar is the more difficult of
elimination. My usual practice carries me into a somewhat tedious individual
excision of each scar in addition to the central core. Frequently, however, a
compromise is carried out by the removal of the more important of the
radiations, leaving the lesser to time and the end of the war: a method
which hastens the man's return to duty and conserves the energies and time
of the theatre staff for more important work. Not only the scar but the
depression should be removed, and for this purpose it is of great advantage
to roll in local fat and muscle flaps from the surrounding area under the new
line of union, a practice which I have carried out from the beginning, and
which is described in detail in Principles.

Apart from the filling of the depressions, which is the most essential part
of the treatment of these scars, the success of the procedure is to be judged
by the character and amount of the residual operation scar.

If a happy result is desired, considerable thought and care must be bestowed
on the details of the skin closure. The incision must be clear of the cicatrix,
not only of the visible but also of the palpable portion. Horsehair, fine and
elastic strands being chosen, gives the best result, as no other suture material
presents this elasticity. Stitch-marks are avoided by taking out the stitches
on the second, third, or fourth day, according to the tension, and by taking up
the tension by deep catgut sutures. If eversion of both edges is required a
mattress suture is employed, if of one edge only, the semi-subcuticular mattress,
while between these everting sutures the simple or the four- twist knot is indicated.
The various little flaps should be brought together and deep catgut inserted,
so that there be no tension on the horsehair edge-to-edge sutures. Frequently
difficulties arise at this stage, and one is confronted with the necessity to make
a decision as to whether the parts can be pulled together without undue strain,
or whether a flap is necessary to complete. It is usually easy to make, by
further incision, one of the little flaps into a bigger one, and so overcome the
difficulty ; and I feel that a guiding principle which stands the tests in most
cases is that " when in doubt, cut a small flap." The fine edge sutures
should receive minute attention, so that the very edges of the cut skin are
apposed. Round the centre of the depression, where the apices of the stellate
flaps meet, suturing becomes difficult. Frequently it is better to put in a
modified purse-string or a mattress method involving more than one flap, as
there is no room for many fine stitches.

REPAIR OF THE CHEEK

FIG. 13. A few days subsequent to a double shell-
wound.

Fio. 14. After the plastic on the cheek and simple
healing of the chin. Note the restoration of cheek
contour, but the indifferent operation scar.

CASE 83

Illustrated in the accompanying figs., requires little elaboration. He was wounded
by shell, on 23.7.16, in two separate places, each wound being of an explosive
nature. The wound of the chin, as shown in fig. 13, healed of its own accord,
without any operation (see fig. 14), while the wound of the left antrum healed with
a large depressed scar which was treated by excision of the scar tissue, and by
rolling in fat-flaps, as described in the chapter on Principles. It will be noted that
the patient's left eye was enucleated in the early stage by the ophthalmic specialist
on account of the injuries it had received. The scar tissue was widely excised
under general anaesthesia, and local fat-flaps were turned in to fill up the missing
contour and sutured with catgut, the skin being united with interrupted horsehair
stitches. The photographs, taken on the patient's discharge from hospital, show the
result of this simple procedure.

In criticising this result, it appears obvious to me that the whole scar was not removed,
and that, had palpation been made, the edges of the wound would have felt hard and un-
yielding. The consequence of leaving this indurated subcuticular area is that the edge
has remained heaped up in places, and does not lie as flat as it would otherwise have done.
The condition is, of course, eminently suitable for further treatment in the way of re-excision,
but such would probably have been unnecessary had the above-mentioned precautions
been taken in the first instance. However, even when the whole scar tissue is successfully
excised, the first operation scar is not usually as good as when a second or even a third
linear excision is undertaken, suitable intervals being allowed to elapse between operations.

lo PLASTIC SURGERY

CASE 37

This officer received a long, gashing wound of the left cheek, which is well illustrated.
At its maximum depth, it penetrated to the mouth (buccal fistula), and, during the course
of the missile, the mandible was fractured with loss of bone, mainly alveolar. Two pointed
ends of the lower border of the bone remained in close proximity in the bottom of the wound,
and at the later operation scar tissue was excised between these points, which were them-
selves freshened. Combined with dental splinting and necessary extractions, this freshening
resulted in bony union, so that the injury may be classed as one without loss of bony contour.

The healed condition in a case like this is merely one of a very large depressed scar.
The good result obtained was due, I think, to the use of fat flaps, as previously explained
and as the diagram represents. On this occasion they were rolled in towards the depression,
having their blood supply from the deep tissues : the skin, thus undercut, was drawn over
the fatty prominence and accurately sutured. The skin edges were cut markedly on the
slant or bevel, and the stitch used was the semi-subcutaneous horsehair mattress suture
(vide p. 33), reinforced by a few edge-to-cdge stitches. The upper part of the scar was
invisible as such before this patient left hospital, but there was still a slight depression
which marked its site.

The final history of this gallant officer from the Dominions is pathetic. Soon after
being posted back to duty he volunteered for foreign service again, was shot through the
knee-joint, and died of wounds in the same Casualty Clearing Station as that which received
him when his face was wounded.

REPAIR OF THE CHEEK

i g. On admission 10 days after wound. Lower
facial paralysis.

Fid. 1G represents^fat flaps rolled in towards
the centre of the depression.

FIG. 1 7. Result. Note : the smudge beneath the
chin was a result of shaving, and has been removed on
the print. There was no appreciable facial paralysis
at this stage.

42 PLASTIC SURGERY

Literally one might give hundreds of examples of these scars and of the
results of their excision, and I need only here refer to my remarks in Chapter
I, p. 33, where I have discussed the production of invisible wound scars.

(6) WOUNDS OF THE CHEEK, WITH LOSS OF SOFT

TISSUE ONLY

Here, again, the definition of this class can be no more than arbitrary,
as some of the examples are merely extra large depressed scars, while others
include in their lesion a loss of bone. They may be described as cases
requiring the provision of flaps, but not including any serious operation for
the restoration of the lost bone.

CASE 27

Gunner P. was wounded 22.7.16, and admitted to me on 10.12.16, in the healed
condition, as shown in fig. 18. There was a large loss of soft tissue involving the
left corner of the mouth and the region of the cheek extending outwards from this
corner. The wound had healed by scar tissue, and besides considerable deformity,
there was much loss of function through contraction. The first operation I per-
formed on 10 . 1 . 17 was a complete failure, due entirely to a haematoma which
formed under the flap. The flap had to be raised in order to evacuate the blood :
none of the stitches held. The condition when healed, after this unfortunate occur-
rence, was practically the same as on admission, but
with one additional scar. On 5.3.17, the con-
dition had been healed so long that a second
operation was judged to be possible. On this
occasion a large thick musculo-cutaneous flap, in
breadth about 1 in., was taken from the left naso-
labial and left infra-orbital regions and swung down
towards the corner of the mouth (where, after
the excision of the scar, there was a large deficiency
of skin and muscle), as shown in the diagram,
fig. 20. The scar tissue excised at the corner
of the mouth included about a third of the upper
lip, and did not penetrate farther than the deep
surface of the mucous membrane of the mouth.
On attempting to fit the flap in at the corner of
the mouth, I realised that it had to be split, the
larger portion going to the upper lip and the
smaller to the lower.

Another interesting point in this case is to
be observed in the fact that a large flap can be
taken from this region without causing serious
secondary deformity. The result of this operation
was very satisfactory, and the value of a split
flap at the corner of the mouth is established
by this case and by Case 220 (page 56). This
-Actual loss greater than apparent. patient was discharged from hospital on 1-1.5. 17.

REPAIR OF THE CHEEK

Fio. 19. Flap.

FIG. 20. Suture. Note splitting of flop to form
angle of mouth.

FIG. 21. After plastic. Lips apart, lower scars
not treated.

FIG. 22. After plastic. Lips closed. Split flap
to form corner of mouth.

1 1

PLASTIC SURGERY

CASE 292

Fig. 23, of this case represents the condition of Sergeant 15. on admission into
this department on 15.6.17. IK- was wounded on 10.9.10. Previous notes and
photographs are not available. lint it is obvious that he had a shell wound pene-
trating the left antnmi, with the loss of infra-orbital plate, and a large depressed
scar on cheek. The sear was excised on 14.7.17, under general anaesthesia, and a
large fat graft, measuring .'5 in. by 2| in. by ? in. thick was taken from left buttock
and fixed" in the depression by "catgut. Everything proceeded normally until the
fourteenth day, when first fat necrosis, and subsequently suppuration occurred.
necessitating drainage from the centre and from the dependent portion of the sear.
This suppuration continued for about four weeks. His condition when the suppuration
ceased is shown in fig. 24. I illustrate this case to show that, although a fat graft

Fia. 23. On admission healed.

FIG. 24. Left eye enucleated. Fat graft to cheek.

may not succeed in toto, yet, even if it suppurates, very considerable improvement
in the contour is invariably produced. In order to complete this case, it appeared
advisable to implant a cartilaginous plate to take the place of the lost infra-orbital
margin.

At the same time, it. was decided to utilise a piece of cartilage for a prosthesis
of the eye socket, which was of a very shrunken character.

Two operations were therefore carried out at the same time on 10.9.17. An
incision was made parallel to the lower lid and over the infra-orbital margin, and the
skin undermined in the neighbourhood. A piece of cartilage, composed of a portion
of two adjacent rib cartilages, was removed for me by Captain H. Montgomery,
H.A..M.C.. IVoni this patient's right thorax, the attachment between the two rib
earl Mages being left undisturbed. It was pared with the knife until it was of such a shape
that the (( ml our was accurately reconstructed, placed in position, and the skin reunited
over it with siibcut icular horsehair. The sternal end of the 7th cartilage was then taken, in

REPAIR OF THE CHEEK

its whole thickness, and shaped into a cup and ball, as described in the chapter on Eye
Plastics, p. 339. These two pieces of cartilage were inserted into the depths of tin-
eye-socket through an horizontal incision made in the conjunctiva. The two wounds
healed by primary intention, and, after the fitting of an artificial eye, the result was
very satisfactory. Diagrams illustrating these later operations are appended.

FIG. 25. After cartilage grafts to socket and cheek.
Artificial eye fitted.

Flo. 26.- Ditto. Same stage<

Sec tion

Cartilage
, Prosthesis,

of L. Socket

\ X 7 C M Costal
N 8 ^[Cartilage

FIG. 27. Diagram of cartilage implants.

PLASTIC SURGERY

CASE 73

Represents a type of case in which there was partial loss of the malar bone and
fracture of the lower jaw. The deformity is not one which calls for definite recon-
stitution of the bony framework.

Private C. was wounded on 1.7.16, and his condition on admission on 6. 7. 1C
is shown in fig. 30, the result of a severe shell- wound. On 29.11.16 Lieutenant
C. B. Tudchope, R.A.M.C., performed an operation. The large scar, extending from
the outer orbital angle to half an inch below the lobule of the left ear, was
excised. The fibrous tissue was so thick that the dissection led down to the remains
of the malar bone and horizontal ramus of mandible. This dissection completely freed
the lobule of the ear. In order to build up the contour, local fat-flaps were turned
in and sutured with catgut but, owing to this being insufficient, a small free fat-flap
from the buttock was implanted. The wound was closed by relaxation and horse-
hair sutures, without drainage, the lobule of the ear being adjusted to position.
Moderate suppuration of this fat-graft occurred, but the condition shortly before
discharge was as shown in fig. 31. The fracture of the lower jaw necessitated the
patient's stay in hospital for a longer period, and he was not discharged until 21.4.17.
It is obvious that this wound involved the destruction of branches of the temporo-
facial nerve.

Fio. 28. " Natural " flaps made by excision of scar.

Fio. 30. Five days after wound.

Fia. 31. Result plastic. Note : upper facial paralysis
only.

REPAIR OF THE CHEEK

CASE 33

In this case the wound of the left cheek was complicated by loss of bone in the upper
jaw. The wound also extended from the left corner of the mouth and opened widely into
the buccal cavity. Unfortunately I have no record of the healed condition, and in view
of one's experience, this spectacular result is to be, to a certain extent, discounted. The
first operation (27.10.16) was performed three months after his shell- wound. The aim
was to reform the corner of the mouth, adjacent portions of both lips, and a considerable
amount of check ; and a large dense scar had to be excised. The mucosa was carefully
dissected and sewn to reform the buccal lining and to complete the upper lip. My notes
read that there was much less loss of tissue than was expected.

The result was gratifying, but as a considerable amount of scar tissue remained on the
edges after excision of the main part of the scar, the line of union was not expected to be
perfect. A particular twist of a mucous flap satisfactorily formed the corner of the mouth,
and the wound healed well.

Two months later, a second operation was performed : the scar was excised, and fat
flaps sutured beneath the line of incision, which was closed with horsehair sutures. In
order to complete the case from a dental point of view, an extensive incision was made
along the left alveolar border of the maxilla and a vulcanite plate inserted, held in
position by elastic traction from a dental splint.

A denture was then adapted to the upper jaw, but I heard later from the patient that
it had to be altered, which probably meant that scar tissue was reforming (vide notes of
case 128, p. 60). Patient discharged on 14.3.17.

FIG. 3-. Soon after wound.

Fia. 33. Result of plastic. It is unfortunate that
the healed stage of this case was not recorded.

PLASTIC SURGERY

CASE 41

This is an example of a large soft-tissue de-
struction of the cheek and upper lip together
with a small loss of the underlying alveolar bone
of the maxilla. The tip and left ala of the nose
arc likewise shot away ; but the interest of the
repair is confined to that of the check. The first
photograph shows the suppurating and granula-
tion stage of the wound 10 days after the injury.

Two months later the plastic operation was
performed, by which time the wound had healed
by dense scar formation. This latter was freely
excised, and the picture on the operating-table
after such excision very closely resembled that of
the original wound. The repair was made by
transposing a large flap (A) from the side of the
chin and submaxillary region of the same side, i.e.
an ascending flap. Despite a mild infection, the
repair was good. The secondary gap caused by
raising flap A was closed with some difficulty,
which was somewhat eased by 'a secondary in-
cision (X) represented too short in the diagram.

No attempt at rhinoplasty was performed at
this stage, but later an effort with small local flaps was made to modify the nasal defect with
but poor result. There is no question, in view of the later development of rhinoplasty, that
an excellent repair could have been effected on the lines of a turncd-in flap, to complete
the lining of the tip and left ala, and of a covering from the left frontal region carried on
a tube-pedicle flap, as in case 627, p. 244. Patient refused further treatment.

FIG. 34. Wounded, 1.7.16. Condition, 1 1 . 7 . 1 G.

Via. 35. Result 4 weeks after operation, per.
formed 19.9.16. No attempt at rhinoplasty.

FIG. 30. Excision and flaps.

REPAIR OF THE CHEEK

CASE 144

" Loss of soft tissue without serious loss
of the underlying framework " is the category
in which I put this case. The patient was
wounded on October llth, 1916, and was
admitted to me on 17.10.16. The wound
is a very remarkable example of the explosive
type and it is instructive to note how this
patient's enormous gaping wound healed
without more than ordinary surgical methods.
I think this case teaches a lesson to the in-
experienced in regard to the way the camera
occasionally represents an inaccurate concep-
tion of the wound. Thus, fig. 38 repre-
sents the condition when the tissues were
healed, without any plastic operation what-
ever.

The further treatment of this case was
undertaken by Captain J. L. Aymard,
R.A.M.C., and consisted of excision of scars,
with satisfactory results.

FIG. 37. Condition on admission.

FIG. .'{8. The result of healing without any
operation.

Fia. 39. After 1st excision of scar. Note : no general
facial paralysis.

PLASTIC SURGERY

CASE 296

This case, Private W., wounded on 1.7.16, and admitted a week later, is an
example of buccal fistula situated in the exit wound of a bullet which entered the
left check and carried some teeth through the right cheek. In fig. 40 is shown the
exit wound with buccal mucous membrane everted through the hole. The corner of
the mouth just escaped destruction. This is one of the cases in which early opera-
tion is indicated.

An operation was performed on 21.7.16 under general anaesthesia. The buccal
mucous membrane was dissected up, invaginated, and retained by two rows of purse-
string sutures. Accurate suture of the rest of the wound was not attempted at this
stage, but approximation of the skin was produced by means of the method shown
in fig. 41. Pieces of blanket flannel, to which are sewn dress-hooks, are fixed
with collodium to each edge of the wound and the hooks are then united by rubber
bands. Drainage was provided. This method, as advocated by Kazan jian, is very
valuable in the early approximation of wounds when deep sutures are liable to
suppurate and to produce more scar tissue than was previously existing. The result
of this operation was very satisfactory ; no salivary leak occurred and the wound
healed by good secondary union. There was a long, irregular, depressed scar still
present at the end of two months. This scar was then excised, but there was a slight
breaking-down near the angle of the mouth. The scar was re-excised some six weeks
later. The result, as shown in fig. 42, was practically perfect and the man was
discharged from hospital to duty on June 13th, 1917.

Fid. 40. Buccal fistula.

FlO. 41. Use of approximating hooks
and clastic (Kazanjian).

FIG. 42. Result of plastic and
excision scar.

REPAIR OF THE CHEEK

CASE 101

Lance-Corporal W., wounded on 7.10.16, was operated on by me on 15.1.17. The
wound involved part of the malar and zygomatic ridge. It will be noticed also that botli
eyelids are involved in and dragged outwards by the scar. Two flaps were raised on each
side of the scar ; from the lower a local fat-flap was turned upwards, while from under
the upper flap a small portion of the temporal muscle, with its overlying fat, was turned
downwards. The result as to the contour was good, as is shown in fig. 44. Under local
anaesthetic four months later, an attempt was made to release the eyelids from the outward
drag. This was only partially successful, the method used being to make an incision \ in.
external to the outer ocular angle, \ in. in length across the line of the scar and to sew up
this perpendicular incision horizontally. To further raise the scar a small tunnel was made
from this incision in a backward direction and a small amount of paraffin wax imbedded.
This was only partially retained.

I do not consider that either of the last procedures is to be recommended. In order
to release the outer canthus correctly either a flap should have been laid in between the
end of the scar and the outer ocular angle, or else a sufficiently large skin-graft applied to
produce the same effect.

In regard to the insertion of paraffin, I cannot express too strongly my disapproval of
using this irritant foreign body. Undoubtedly the best method of using paraffin is to imbed
a definite quantity of it into a prepared pocket. The immediate results are often very
pleasing. But there are so many examples known to all surgeons of chronic thickening
of the parts, induration of the skin, paraffin tumours and other complications, that its use
should be strongly deprecated, not only in this work, but also in all forms of civilian cosmetic
surgery.

Flo. 43. -The healed stage. Loss of bone in malar
region. Outer canthus dragged out by scar.

Fio. 44. Result after an attempt partially successful
to relieve the drag on the outer canthus.

52 PLASTIC SURGERY

The severer injuries of the cheek include those in which there is loss of
the bony frame-work. One particular group (1) is well defined, viz., that in
which the malar prominence is wholly or sub-totally lost. I have chosen
to illustrate this group by four cases which have been treated by means of
the temporal muscle turned forwards subcutaneously. In one of the cases
(40) a previous unsuccessful implantation of a celluloid plate was made and,
in the following case, a thin celluloid plate was inserted over the temporal
muscle flap with satisfactory results.

CASE 28

This patient was received in a healed condition on 18.5.16, as shown in fig. 45.

He was wounded 26.9.15, eight months previously, no record being available
as to his previous condition. On 30.6.16 I operated under general anaesthesia.
After excision of the scar, an extension of incision into the temporal region enabled
me to detach the anterior two-thirds of the temporal muscle. This muscular flap
was separated from the rest of the muscle and swung down into the depression
caused by the loss of the malar prominence, in which position it was sutured
with catgut. The lower part of the wound was filled up by means of local fat -flaps.
Horsehair was used for the skin edges. In fig. 47 the result of this operation is
shown. The dimple underneath the left eye is due to the deep suture above referred
to, which retains the temporal flap in position. Primary union followed this operation.
1 was not satisfied, however, with the reconstitution of the left orbital margin ;
hence, a piece of shaped rib cartilage from the right thorax was taken and inserted
subcutaneously to form the outer orbital margin. An acute infection followed this
operation, performed on 21.7.16, which owed its origin to the proximity of the
orbital cavity, and the graft was removed to avoid the possibility of orbital cellulitis.
The condition rapidly cleared up and on 7.9.16 some of the scar tissue was excised
under local anesthetic (novocaine). On 14.10.16 a final operation was performed for
the still further improvement of the contour and scar. The upper part of the vertical
scar was excised, skin cut on the slant, and a bed made for a triangular smooth
piece of celluloid, which was implanted. The skin edges were carefully sewn up
with horsehair. The result of these operative procedures is shown in fig. 46.

An interesting after-history of this case is that, on 26.3.17, this man was re-
admitted suffering from a localised abscess over the centre of the celluloid plate and
line of the scar. The abscess was located between the celluloid and the skin and
had not burst. The celluloid plate was freely movable and the abscess was not painful.
Within a week suppuration had ceased and the patient was again discharged with
the celluloid plate still in place. It is interesting to note that this is one of
the few celluloid-plate implantations which, in my experience, have been retained.
Another point of interest in connection with this case is the suppuration following the
cartilage graft operation. In view of later experience with cartilage, I believe that
had this suppuration been drained, there is the possibility that a large amount of the
cartilage might have been retained, and that I was over hasty in its removal.

REPAIR OF THE CHEEK

FIG. 45. Healed condition.

FIG. 46. After insertion of thin celluloid plate.

Fid. 47. Soon after temporal muscle implant.

PLASTIC SURGERY

CASE 40

Is the next example of this group. The healed condition of this case will be seen
in fig. 48. Private F. was wounded on 7.7.16. The wound caused loss of the
right eye part of the lower lid and the malar prominence, combined with the external
portion of the orbital ring. At that time I was giving celluloid plate implantations a
thorough trial and a piece of celluloid i in. thick was cut in the shape of the missing
bony substructure and implanted in situ. The result was a failure, as ha?matoma and
suppuration followed, and the celluloid had to be removed. On 30.1.17 it was possible
to perform a second operation. After excision of the scar, the temporal muscle flap
was swung down in the usual manner to make good the contour but, in this case,
I improved the operation by making the temporal incision in the hairy scalp. This
" inverted U " shaped incision is shown diagrammatically in fig. 50 and the earlier result
of this particular operation is shown in fig. 52, while the later result of the implantation,
witli the addition of an artificial eye, is to be seen in fig. 53.

FIG. 48. The healed condition showing
large malar loss and dragging down and
out of the outer canthus.

Celluloid. Kiji

FIG. 49. The first operation included the im-
plantation of a shaped piece of celluloid. Failure.
Removed.

It should be noted that, in swinging this temporal muscle forwards and downwards,
the intervening skin had to be undermined and raised to allow the muscle to be passed
underneath it.

Care must be taken to detach the temporal fascia from its zygomatic attachment.
When this is completed the muscle flap usually comes forward as far as is necessary. In
some cases I have advanced it considerably further by dissecting downwards towards the
coronoid process, at the back of the muscle-flap. When this is done, the end of the muscle-
flap can be easily stitched to the periosteum at the side of the nose, vide Case 215, p. 71.
Even in this situation the temporal muscle continues to contract.

Two months later a small operation was performed to raise the lower lid at the inner
and outer angles. At the outer angle a small skin-flap was turned into the socket after the
adhesions were dissected out, while at the inner angle a small wedge-shaped piece was
removed to bring the angle more towards the middle line. This enabled an artificial eye
to be carried, but was not entirely satisfactory.

The result was perfect as far as the contour was concerned, and the temporal

REPAIR OF THE CHEEK

muscle, in its new situation, had a certain amount of contractile power, thereby giving
expression. The eye socket and lower lid need further improvement.

This case has recently been seen, eighteen months after the temporal transplant
operation, and the contractile power of the muscle is undiminished.

I MS,

FIG. 50. Incision and preparation for the author's
operation for temporal muscle transplant.

FIG. 51. The flap of muscle sutured into
position.

FIG. 52. Soon after operation. Showing " U "
temporal incision. Note the excellent contour.

FIG. 53. Later. Artificial eye fitted. The
lower lid still requires raising.

PLASTIC SURGERY

CASE 220

Wounded 27.2.17. First operation, 27.6.17. After excision of scar, a flap (fig. 55)
was swung up, and split to enclose the corner of the mouth, the larger portion going to the
upper lip, the consequent gap being filled by advancement of flap ('. (figs. 56 and 57).
Skin and mucosa were sewn separately, to ensure a lining. Mattress sutures were employed
down as far as the upper lip. One or two edge-to-edge sutures were added in the middle
of this part, the result being best here. Elsewhere interrupted sutures were used, giving
a better scar than where mattress sutures were used alone. I do not condemn mattress
sutures because of this experience, as I find that a scar in the temporal region is usually
more marked than one in the mouth region. But I think mattress sutures should be assisted
by the addition of edge-to-edge sutures. The upper six mattress sutures were of thread ;
hence, possibly, the prominence of this part of the scar, the result being otherwise good.

An observation should here be made that in planning the flap for the upper lip, I allowed
slightly for contraction. None has occurred, and I assert that where no raw surface
is exposed, none will occur ; and the teaching that the flap should be cut one-third or more
larger than the gap would appear erroneous. When an epithelial or mucous lining can be
provided, the flap should be the exact size of the gap. The only modification I make on
this has been discussed in Chapter I. I do not think it advisable to undertake plastic
operations involving mucous cavities without seeing that the complete lining is available.

A second operation on 13.3.18, consisting mainly of excision of the redundant portion
of the flap above described, resulted in great improvement of the line of the lip. At the
same time, an ovoid piece of cartilage, from another case, was inserted into the eye socket
through the usual conjunctival incision. The result, after fitting an artificial eye, is shown.
The lower lid needs raising a trifle.

t'ia. 04. Recent wound of cheek and upper lip. Fio. 55. Diagram of excision of scar and of flap, A B.

REPAIR OF THE CHEEK

FIG. 56. Flap, A B t raised and split to form corner
of mouth.

FIG. 57. Suture. Flap, O, advanced to fill gap.
Note relaxation buttons.

Fio. 58. Day after operation, showing relaxation
buttons and horsehair mattress sutures.

FIG. 59. Final result. Lack of muscle power
in lower lid spoils the eye effect.

PLASTIC SURGERY

CASE 192

Is interesting from the point of view of the very large hollow produced by the loss
of the malar prominence, infra-orbital plate and adjacent parts of the superior maxilla.
Though wounded on 24.8.16, this patient was not admitted until 9.3.17, when the
photograph, fig. 60, was taken. Temporal muscle operation was performed on 16.4.17,
but the operation had to be modified by the addition of a skin-flap. It should be noted
that there was a small sinus leading into the left antrum at the bottom of the scar and
the lower lid as well as the left eye had been shot away. The flap of skin was turned
down from the left temporal region from the line of the temporal artery. It is marked
" A A" in Professor Tonks's diagram, fig. 61. This flap was slightly bigger than
is represented and was swung down beneath the eye. In order to fill the gap caused
by the removal of this flap, a swinging flap B was taken from the scalp. The whole result
was a very marked improvement. On arriving at the condition shown in fig. 62, one
has brought into the bounds of possibility the question of the reformation of the left eye
socket. A certain amount of movement is again present in the transplanted muscle.
The secondary closure of the temporal region has resulted in an advancement of the hairy
scalp a condition which is not an unpleasant one.

The lymph-oedema of the upper lid gradually diminished. The treatment of the
eye socket was carried out for me by Captain C. F. Rumsey, R.A.M.C., who did a Tripier
operation, i.e. swinging a stirrup of skin from the upper to the lower lid, the flap ends
remaining attached for the blood supply to both ocular angles. The resulting condition
was such that the socket could retain a glass shell.

At this stage the patient was discharged from the Army, to return later for the com-
pletion of the eye socket.

Fid. 60. The healed stage showing large malar,
and infra-orbital bony loss of lower lid, etc.

FIG. 61.- Shows author's temporal muscle-flap being
brought into position, and a temporal skin- flap, A A, to
be swung down beneath eye to A' A'.

REPAIR OF THE CHEEK

The further treatment will probably consist of the insertion of a thin strip of cartilage
into the lower lid to retain it at a correct level. It may be necessary to deepen the socket
by means of an epithelial inlay.

FIG. 62. Result of this operation.

FIG. 63. Result of Tripier operation.

FIG. 64. Incision for Tripier operation.

FIG. 65. Suture.

PLASTIC SURGERY

CASE 128

Is not unlike the one which directly precedes this. Rifleman B. was wounded
on 3.9.16 and admitted shortly after this date. No photographic record of the
condition at this stage is available but on 15.2.17, the day of operation, the
deformity was as is to be seen in fig. 66. The outer third of the left upper lip was
drawn upwards and inwards and bound down against the ala of the nose, leaving a
triangular opening in the cheek with the base downward. The apex of the triangle
"|K'iis into the antrum while a large scar radiates out into the cheek from the outer
extremity of the gap. The lower lip is involved in this cicatrix and is drawn

upwards.

Operation was performed on 15.2.17. The scar tissue was excised and the

lips freed. A small flap of skin from the
upper and lower margin of the gap was turned
to complete the epithelial lining of the aper-
ture, so as to prevent cicatricial contraction
later. To meet this inverted epithelial flap,
a mucous flap was drawn up from inside the
left cheek. The mucous membrane at the
angle of the mouth was completed by swinging
round a portion of the lower lip and suturing it
with deep catgut and superficial horsehair
sutures to the free edge of the upper lip.
Diagram 67 illustrates the method of freeing
the upper lip. The corner of this lip was
brought down to help to form the corner
of the mouth. The flap was then outlined
and swung up to complete the closure. It will
be observed that in fig. 68, a vulcanite support,
taking the place of the alveolar margin where
it was wanting, has been fitted by the dental
surgeon. It was retained in position until the
wound was well healed, which occurred with-
out untoward symptoms. Black silk was used
on this occasion to unite the skin edges.
(25.1.17.) Some intra-buccal adhesions were
cut by Captain C. F. Rumsey to allow a
satisfactory denture to be fitted. Photograph,
fig. 69, shows the condition on 16.7.17.

In regard to the cutting of intra-buccal
adhesions, I feel very strongly that this is a

method which docs not often succeed ; more frequently than not it produces more scar
tissue than before the treatment, and anything in the nature of an extensive freeing of the
lip or cheek by the underlying bone by undercutting and insertion of a dental appliance is,
in my experience, doomed to failure. I admit, however, that where the loss of mucous
membrane is minimal and where there is a definite band of scar tissue this can sometimes
be dealt with by this method. In all other cases recourse should be had to the epithelial
inlay method of Esser.

Fio. 66. The healed condition, 15.2.17. Note
the shield on the obturator, also the iodius which
spoils the photo.

REPAIR OF THE CHEEK

FIG. G7. Scar excision and incisions. The inverted
skin and mucous membrane flaps cut to complete the
lining are not shown in this diagram.

FIG. OS. Suture.

Fia 01). Result, 16.7.17.

PLASTIC SURGERY

CASE 14

The illustration, fig. 70, is an example of a very extensive cheek wound with
loss of the supporting bony structures, especially of the superior maxilla. The corner
of the mouth and left half of the upper iip were involved in the destruction.
Wounded in the battle of the Sommc, the first plastic operation was pcrfoimcd thice
months later, on 4.10.16, on which date the condition is as shown in fig. 71. Dur-
ing this period the dental surgeon had made successful efforts to reduce the fractures
of the upper and lower jaw and the healing process apparently diminished the loss
of tissue. However, on excision of the scar, there was a very extensive gap, not
considerably less than that shown in the original wound photogiaph. To meet this
difficulty, two large flaps both of a swinging variety were taken. The larger one, A,

comprised the remains of the soft tissues of the
cheek and was defined by means of an incision ex-
tending from the side of the nose and carried outwards
beneath the eye to the malar prominence; while
the lower flap, B, was outlined by an incision carried
down from near the corner of the mouth to below
the mandible in the sub-maxillary region. These
two thick flaps were widely under-cut and swung
towards each other ; the upper flap completed the
gap above the level of the mouth, while the lower
one was sutured along its lower border. Owing to
the large deficiency of mucous membrane, it did
not seem possible to complete the mouth in its
original size and some sacrifice in length of the lips
was perforce made. Relaxation sutures were inserted
to retain the untouched part of the lower lip to the
large cheek flap. Drainage was provided at a suit-
able spot. The result of this plastic operation was
very satisfactory in so far as one operation pro-
duced a result which satisfied the patient ; but it
left the man with a whimsical, one-sided expression
which, however, was not entirely unpleasant. The
rest of the treatment for this patient consisted in
the effort to get union of the right horizontal
ramus of the mandible. An extensive freshening
of the ununited fragments was carried out on 11.1. 17,
but no union resulted after a period of three

months. On 25.4.17, the fracture ends were again exposed but, although found to be in
good apposition, there was no bony union. The surfaces were again freshened, drilled
and wired together with strong iron wire. This operation was carried out by Captain
J. L. Aymard, R.A.M.C., and Captain F. E. Sprawson, R.A.M.C. No union had occurred
at the end of two months but, at the end of five months, there was clinical union
of the fracture and the patient was fitted with an upper and lower denture which
enabled him to eat a semi-solid diet. He was discharged from the Aimy unfit for further
service.

FIG. 70. Showing condition a few days
after wound on 1.7.16. Compare this with
the healed stage, which gives a truer con-
ception of the loss of tissue.

REPAIR OF THE CHEEK

FIG. 71. The healed condition, 4.10.16.

Fio. 72. Diagram showing excision
of scar and flaps cut.

Fio. 73. Suture.

Jfc

Fio. 74. Early result operation, October 1910.

Fio. 75. September 1917.

PLASTIC SURGERY

CASES COMPLICATED BY SUPERIOR MAXILLARY LOSS

A less defined group is one in which the bony support of the upper jaw
is missing. The loss of bone may be in the alveolar process, the anterior wall of
the antrum or in the infra-orbital plate. When the combined bone and skin
lesion is not great, the difficulties are overcome with very satisfactory results ;
but when there is a great loss of both soft and hard tissues, as in Case 215,
the problem is one requiring much thought.

CASE 4

This man was wounded in the upper jaw and cheek, including the corner of the
left upper lip, by a shell, on 1.7.16. The bony loss consisted of the alveolar process
and the lower part of the antral wall. The condition cleared up sufficiently to allow the

FIG. 70. On admission three weeks after wound.

first plastic operation to be peiformed on 29.9.16. The irregular scar was widely excised.
The gap produced by this excision is well shown in diagram, fig. 78. In order to close
this gap a large swinging flap, A' B', was swung upwards to meet A B, and the mucous
membrane at the corner of the mouth was rearranged. On 2.11.16, some six weeks
later, the scar tissue was excised and fat-flaps brought to fill up the hollow ; this was
sutured with catgut, the skin with horsehair. The final result, seen in fig. 81, is
sufficiently satisfactory. When fitted with dentures on discharge from hospital, the
patient was able to eat most articles of diet.

REPAIR OF THE CHEEK

FIG. 77. The healed condition.

FIG. 78. Diagram representing excision FiQ. 79. Diagram

of scar and cutting of flap A' B'. of suture.

a. 80. Result of operation, 2(1. 9.1(i.
Intermediate stage.

Fid. 81. Result of operation, 2.11.16.
Photo taken, 2 1.11. 1C.

PLASTIC SURGERY

CASE 142

The early condition of Private R. C., of the Scottish Rifles, wounded on 1.9.16,
is represented in the accompanying figure 82. The condition had so far cleared
up that I was enabled to perform the first plastic operation five weeks after this
patient was wounded. Unfortunately the photographic record of his healed con-
dition is missing. Too much was not attempted and the result was sufficiently
satisfactory. Fig. 88 shows the result of this operative procedure, of which
records were not accurately kept. But the large hole in the left cheek, involving
the angle of the mouth and a portion of both lips, was closed by two swinging
flaps, one from above and one from below. A further plastic operation was per-
formed by me three months later and, here again unfortunately, the details are not
available. The condition after this, when healed, is as shown in fig. 83. At this
.stage, Captain Aymard undertook to finish the condition. After excising the scar, the
lip was raised and sewn by the method shown in Professor H. Tonks's diagrams, the
result being all that one could expect.

Fio. 82. Wounded on 1.9.16. Showing condition
a few days later.

FIG. 83. Showing result of two plastic operations
(author), 10. 10. 1C and 3.1.17.

REPAIR OF THE CHEEK

//?-<-^

FIG. 84. Diagram (Tonks) of operation to raise corner of mouth.

FIGS. 85 and 80. To show result of operation, 13.3.17 (Aymard).

(IS

PLASTIC SURGERY

CASE 49

Is another example of the ravages of shell. This private of the Royal Minister
Fusiliers, whilst still in the condition shown in the photograph, fig. 87, was found
one morning looking in the mirror and smiling with the remaining side of his face.
His excuse for his amusement, he explained to his medical officer, was that he was
thinking " phwhat an aisy toime the barber would have in future." This is charac-
teristic of the cheerful resignation of face cases in general. The extensive injury in
this patient comprised a large loss of substance of the left cheek, corners of the
mouth and upper lip, together with the anterior and inner walls of the left antrum
and alveolar margin. Strong cicatricial bands formed between the maxilla and
mandible, the body of which was likewise fractured. An injudicious attempt to
form the mucous lining of this cavity was made on 26.10.16 without, at the same
time, closing in the gap by skin-flaps. Although the operation was carried out with
great care and accuracy the want of skin covering over the mucous membrane flaps
led to mal-nutrition of the mucous membrane and the giving way of the stitches. I
have tried this method of building up the lining at a separate sitting to the covering
both of mouth and nose openings, but have not had satisfactory results. Both lining
and the covering should be done at the same time or, if it is impossible to find a
lining, the covering should be epithelialised first. On 6.1.17 the patient still
showed a very deep depression on the left side of the face, communicating widely
with the nasal cavity. Much granulation and scar tissue was present, involving the
left portion of the upper lip. The covering to this gap, after extensive excision of
scar, was formed by two advancing flaps from the cheek, as indicated in the dia-
gram, fig. 88. Similarly, the upper lip was cut across below the nose and sutured
to the freshened surface beyond the angle of the mouth and, to round off the angle,
a small mucous flap was turned upwards from the lower lip. An attempt was then
made, by means "of a free muscle graft taken from the vastus externus, to close

over the hole into the nose and to fill up the
contour. The closure was then completed, a
relaxation suture being used to relieve the tension.
The whole of the muscle graft became infected
and apparently sloughed out. This is borne
out in other similar experiences where the graft
is exposed to a mucous cavity. Its place, how-
ever, is taken by granulation tissue and later
fibrous tissue which very materially aided in the
final treatment and enabled me, three months
later, to implant a piece of cartilage to make
good the loss of contour. At this operation,
date 11.4.17, there still existed a small per-
foration into the nose which was closed by
turning in over it small scar tissue flaps. A
plate of cartilage about 2 in. by 1| in was
taken from the right thoracic wall. The result
of this implantation was satisfactory from a
cosmetic point of view but, surgically speak-
ing, it was not gratifying on account of a
small leak into the nose, causing later infec-
tion of the graft. The infection was of a
mild character, however, and was controlled by
Hicrs cupping. The result is shown in photograph,
FlG. 87. Healed, 20.10.18. fig. 90.

REPAIR OF THE CHEEK

Fia. 88. Scar excision and flaps. FIG. 89. Suture.

Note : another incision along the upper lip is missing in the diagram.

FIG. 90. After plastic and cartilage implant.

70 PLASTIC SURGERY

CASE 105

Is a typical example of the shattering effect of an exit wound of a high velocity
projectile which came into contact with a dense piece of bone. A considerable
portion of the right angle of the mandibles as well as the tissues overlying it, were
blown away, producing a large buccal fistula. After many months of suppuration
and operations for scqucstrotomy, the wound eventually healed. Bits of the mandible
had been blown down into the neck and one piece was removed from the right stcrno-
mastoid. Examination of notes made at the time of the first plastic operation reveals
that there was a deep scar over the region of the right angle of the mandible and
radiating in all directions.

On 16.1.17 this operation was performed. Under general anaesthesia the scar
tissue was carefully dissected out. Eatty tissue in the form of flaps was swung
over the deepest portion of the wound and sutured into place. The skin edges
were completely united with continuous silk suture. Examination on 12.3.17 revealed
that the result of the previous operation was excellent, except that, from a contour
point of view, there was too much prominence just anterior to the angle of the jaw.
On examining X-rays, this prominence was found to be due to the fact that the body
of the mandible had been split into two halves by the projectile and that the union
with the ramus had taken place by attachment to the inner plate, while the lower border
of the body had been deflected outwards and stood out as would an exostosis. It
was decided to remove this prominence of bone and to cut a flap of thick tissue to
be swung backwards toward the angle to simulate that prominence. The result of
this procedure, on 12.3.17, was satisfactory in restoring the contour of the jaw. At
this time, the right antrum, which was still somewhat infected, was drained through
the nasal fossa. There still remained a certain amount of scar tissue which was excised,
at my request, some five weeks later by Captain Ayniard. Owing probably to tin-
fact that this operation followed too soon on the above, no further improvement was
obtained, as there was some slight sloughing.

I think the most astonishing feature of this case is the fact that union of the mandible
was obtained after such a long period of suppuration and exfoliation of bone.

The wound was so septic that the idea of early closure was unthinkable. But the
question arises that if all the pieces of bone that were later exfoliated had been taken away
in the early stages, in order to clear up the sepsis, would union of the mandible have been
obtained ? I hardly think so. In my experience, as a rule, this class of explosive wound,
with buccal fistula, rapidly cleans up on account of the free drainage. But in this ease-
pieces of bone had been driven down, not only into the sub-maxillary region, but also as far
back as the sterno-mastoid ; the drainage, though apparently adequate, was not really so.

Fio. 91. Explosive type exit wound. FI G . 92. After moderately successful plastic attempts to

improve the contour.

REPAIR OF THE CHEEK

CASE 215

One of the most extraordinary examples of loss of contour that I have had under my
care. Literally the whole cheek and its supports have been blown away ; the left
lower eye-lid, swollen with lymphatic obstruction and dragged down by scar tissvic,
is all but joined to the angle of the mouth, which is likewise distorted by the cicatrix.
Excepting a thin plate of the ascending ramus of the lower jaw, the mandible has
been destroyed from the first molar region to the joint. The left eye has been enucleated.
Working in conjunction with Captains C. F. Rumsey and Robertson, under whose care
this case was placed, it was decided to replace the remains of the superior maxilla
and mandible as far as possible into their normal positions. An impression of the
upper jaw is shown in fig. 93, which shows the extraordinary approximation of the two
alveolar borders.

First of all, the scar tissue was excised at the left corner of the mouth and
carried out so that a large opening was made into the buccal cavity. The healthy
mucous membrane was drawn out and stitched round to the margins, so that there
should be less scar formation. In regard to the mandible, there was a plate of bone
representing the left ascending ramus lying inwards from its normal position and
having no connection with the joint. Its connection to the scar tissue and to
the anterior fragment of the mandible was cut and, thus mobilised, it took a more
normal position. As far as the maxilla was concerned, a small chisel was entered
between the left canine and lateral incisor region and driven backwards along the
palate without injuring the mucous membrane on the oral surface. This mobilised
the left half of the palate so that it could be easily replaced into normal position. It
was held there by a temporary support while a proper cap splint was being made.
This was fitted in a few days and worn for some months. The impression of the
palate as it is now, is shown in the accompanying fig.- 94.

FIG. 93. Model of palate before its forcible
replacement.

FIG. 94. Same after the left half of the palate had
been levered into position and retained there by
appliance.

About five months later the plastic operation proper was performed, on 7.12.17.

The principle of this operation may be described in the following manner : The
mucous lining was provided by raising the available mucous membrane from below
and above the gap, as two flaps, and then suturing together. The intermediate, or
supporting structures, were provided by means of a large temporal muscle transplant,

PLASTIC SURGERY

Fids. 95 and 96.
Destruction of the greater portion of the left side of the face. Note the contour.

Fio. 97. Result of opening up wound and forcibly FIG. 98.- Diagram of flaps for next stage. The

replacing left half of palate. Retention apparatus in mucous membrane lining is represented by the shading.
position. C is a post auricular flap.

REPAIR OF THE CHEEK

7 X

FiO. 99. Diagram'of the four cartilage implants.

Fio. 100. Final result.

FIO. 101. Same. Note the difference in contour
as compared with the original.

74 PLASTIC SURGERY

carried out in the usual manner. The anterior portion of the left temporal muscle
was detached from its origin and swung down beneath the eye to fill up the
contour of the check. An incision in the hair line was necessary to get at this
muscle and it was then possible to undermine the skin from the zygomatic region to
enable this muscle to be detached. Deep catgut sutures holding this in position had
for their purchase the left lateral aspect of the nose. The main skin-covering was
provided by a large transposed flap with its base in the left sub-maxillary region
and its apex in the left mastoid region. Its design is well shown in Professor Hcmy
Tonks's diagrams. It met the main deficiency of cheek skin. The area behind tin-
ear, caused by the removal of this flap, was only partially closed by undermining and
advancement of the skin and was left to granulate. The flap healed remarkably
well, as did the granulating area, and this, despite a chronic suppurative otitis media
which was present in the left ear immediately above the site of operation. The
healing properties of this particular patient are indeed remarkable.

There remains to describe the replacement of the eye socket. This was merely
sutured into a higher level after excision of the scar which bound it down to the
mouth region. The corner of the mouth was regulated and reconstituted by a special
cut, which enabled the upturned corner of the upper lip to drop to its normal level.

Examination in April 1918 revealed the fact that the upper jaw was firm in its
new position and, with the strip of bone mentioned above, the remains of the left
ascending ramus of the mandible have become firmly united to the rest of this bone,
thus producing a very considerable functional improvement as far as mastication is
concerned. The jaw cannot be opened to its fullest extent but the trismus is not
of a disabling character.

Having a large piece of cartilage to spare from another operation case, this was
inserted subcutaneously over the manubrium sterni, under local anaesthesia. Five
days later, under general anaesthesia, the cartilage was extracted from its bed and
divided into four pieces, the largest piece being utilised to complete the contour of
the mandible. The second, a long thin strip, was inserted beneath the eye socket
to retain the lower lid at a higher level. The third piece was placed in the external
orbital region, while the remaining piece was inserted into the temporal region, whence
the muscle had been taken.

I am greatly indebted to Major C. W. Waldron, C.A.M.C., for permission to
complete this Canadian case after it had been officially transferred to him for treat-
ment and I had the benefit of his advice and assistance at this latter operation.

It is still doubtful whether a really satisfactory artificial eye can be fitted ; but,
as this man states he is returning to a very cold part of Canada, and is therefore
not anxious to have this fitted, the case is now completed.

"v,

INJURIES OF THE UPPER LIP

CHAPTER III
INJURIES OF THE UPPER LIP

THE repair of the upper lip after gunshot wounds is to be considered from
three main points of view: (1) the provision of the skin-covering; (2) the
provision of the muscular and subcutaneous layer ; (3) the provision of the
mucous membrane lining and vermilion border.

Taking the first of these problems, the skin, the subjects being all men,
it is a great advantage that your flap should contain hair-bearing follicles :
this is more especially the case since it is quite unusual to find an upper lip
that is totally destroyed and does not present portions bearing moustache.
It would seem, therefore, that the flap of election for an upper lip would be
an ascending flap with its base opposite the line .of the upper lip and its
extremity situated in the lateral chin region. This method violates one
important principle, viz. the direction of the blood supply, as it is obvious
that it cuts across the facial artery at its division into the coronary arteries.
It is, however, as a matter of practice, a satisfactory flap, but there have been
occasions when one has lost portions of it by sloughing caused by scar tissue
in the neighbourhood of the blood supply, or when it has been cut too long.
Each case has to be taken as a problem by itself.

The second main method of making new portions of the upper lip is one
which includes the use of descending lateral nasal flaps, with their bases in
more or less the same position as the above-mentioned.

This flap has the advantage of an excellent blood supply, and shows little
tendency to depress the corner of the mouth, which is not uncommon with
the ascending flap. On the other hand, there is no hair-bearing skin in the
flap, and, if the mucous membrane is to be included, there is only a small
available amount under the flap, and its length is limited by the undesirability
of encroaching on the lower eyelid region.

Transference of hair-bearing skin from a distance is the third method of
external covering for a lip. Hair-bearing skin is swung down from the temporal
region, as in Case 324, or from the forehead, or from the temporal region on
tube pedicle flaps as described in Principles.

78 PLASTIC SURGERY

These arc merely methods of getting hair-bearing skin from the scalp to
the lip, and all have the advantage of introducing new tissue to the region of the
mouth and of leaving no secondary facial scars.

A rough comparison of the pros and cons of the three methods follows,
giving ideas which may be found useful in upper -lip plastics.

ASCENDING :

(a) Advantages. Hair-bearing, ample mucous membrane underlying,

wide mouth.

(b) Disadvantages. Blood supply less good, more twist, depresses

angle of mouth if any of lip remains at corner, muscular
movement indifferent. Scars noticeable.

(1) When a scar runs up and out from lip.

(2) When there is accompanying loss of cheek near

upper lip.

(3) For half-lips when there is a good half moustache

remaining.

Fid. 102. Ascending flap. FiO. 103. Descending flap.

DESCENDING :

(a) Advantages. Good blood supply. Angle of mouth not depressed.

Muscular movement good. Scars negligible.

(b) Disadvantages. No hair. Shortness of mucous membrane lining,

apt to be cut too short, and therefore contracts the mouth
and puckers the lower lip.

(1) Where a portion of the upper lip remains near the

corner.

(2) When a scar runs down and out from the mouth.

MIXED :

(a) Advantages. }

(b) Disadvantages.^*^* th SC f "* ab Ve>

remains on the one side (diagram, p. 85), and a loss right

INJURIES OF THE UPPER LIP 79

up to the corner and extending to cheek on the other (see
diagram). This method slews the mouth in toto to one side,
but has given me one good result.

See Case 106, p. 84.
Scalp -flap.

(a) Advantages, -Provides moustache, and new tissue introduced from a

distance, no secondary scars on face. The lining may be pro-
vided at same time by including portion of non-hairy forehead.

(b) Disadvantages.- Blood supply not always reliable (I have seen

several failures due to gangrene), no musculature in flap. The
operation is a considerably larger affair.

in and around base of ordinary flaps. (2) In an otherwise
perfect face where the skin covering only is required. (3)
After failure of other methods.

Fio. 104. Temporal artery scalp flap.

In sub-total and half-lip losses, the same principles are involved, but there
are a few additional methods which deserve mention.

(a) The advancement of the remaining portion of the lip to meet

a new flap.

(1) Advantages. Second flap need not be cut so long.

(2) Disadvantages. Very apt to shorten lower lip and to

make it pout, also to upset the subsequent applica-
tion of a denture.

(3) Indications. Small losses, and to make full use of exist-

ing lip and red margin. No harm is done by this
incision, and it is a useful manoeuvre provided that
the corner of the mouth is carefully preserved.

80 PLASTIC SURGERY

(b) Advancement with parallel cut through existing corner a larger

gain of length is obtained than by the simple advancement.
But derangement of the corner occurs and always requires
a secondary correction, often an enlargement of the mouth.

corner being made. This method has its uses, but my ex-
perience with it is not large enough to see clearly its limitations.
When the cut includes the mucous membrane, the secondary
deformity is very considerable and difficult to correct ; but
when the skin only is slid over the deep tissues to the upper
lip, like one card over another, the secondary deformity is
not serious either functionally or aesthetically.

A further method, and probably the best, is available for a loss of the central
portion of the upper lip.

(d) An ascending whole thickness flap is let in above, through or

below the existing third of lip on one side. This depresses
the angle of the mouth and needs a subsequent correction
at a later date when a portion of this flap is returned to the
lower lip to raise the angle. This secondary correction is easy
to obtain. Several examples are illustrated among the cases.

(e) The ascending bridge flap with hair for moustache is indicated,

when skin only is required. The pedicle is returned to the
cheek. Vide Case 295, p. 114.
(/) Similarly, moustache bridge flaps may be cut from the scalp

and swung down to the upper lip with successful results,
(g) Method of Esser. See Annals of Surgery, March 1917.
Secondary corrections to the new upper lip are of only too frequent neces-
sity. I have seldom produced a satisfactory upper lip in one operation.
Corrections of the level of the mouth corners, of the red margin, of microstoma,
of adhesions between lip and jaw, and of general tightness, all present problems
which cannot be usefully discussed at the present time.

In regard to the second provision for an upper lip, the muscles and sub-
cutaneous tissue, both the main methods of repair above mentioned provide this
tissue body for the new lip. Thus, the ascending flap from the chin region
includes the orbicularis and various portions of muscles attached in the region
of the chin, while the descending flap has muscular fibres.

It is doubtful whether either of these muscular flaps gives as much move-
ment in its new position as the main flap for making a lower lip, which is
mentioned in the next section. But in both cases a certain amount of muscular
function appears to persist, It is, however, to be admitted that the move-

INJURIES OF THE UPPER LIP 81

ments of a new lip are very inferior to that of the normal, and as the form of
the lip depends, to a very great extent, on the normal muscular poise, it is
obvious that the reformation of a normal upper lip is not, so far, within the
maximum of possibility. The most that I foresee as a result is a new upper
lip, which, in a position of rest, gives a normal appearance. The production
of the filtrum is a subtlety which does not seem to be worth attempting
until one has produced a higher grade lip than at present. I have made
attempts, as in Case 177, in which the tissue of the new lip was very thick
under the nose, and gradually became thinner as the red border of the lip
was approached, to roll down the flap of subcutaneous tissue from the upper
and nasal aspect of the lip to the free border. This partially succeeded. It
may be that very thin strips of cartilage inserted under the skin might produce
a satisfactory edge to a lip as well as a filtrum.

In regard to the provision of the mucous membrane, this is a matter
which requires very close examination in each case, for frequently a good deal
of useful mucous membrane has been saved after the injury. Frequently
small flaps of skin in the neighbourhood can be turned, with . their skin
surfaces inwards, to keep the lip free, and, in addition, the ascending flap
mentioned above, which not only contains skin and muscle as well, can be
made to include mucous membrane. In such a case the whole new upper
lip is made with one design. Personally, I have not used this flap on many
occasions, either because it was not necessary, or because some complicating
scars were present. The only disadvantage of taking the mucous membrane
with this ascending flap is a certain amount of shortening of the cheek
mucous membrane, and if there is any septic process occurring after the
operation, one is liable to create adhesions in one or other sulcus affecting
the efficiency of mastication; but, with a well-cut flap and proper attention, I
do not think this complication should occur.

Another method of providing mucous membrane for a vermilion border
of the new upper lip is one involving the transference, in two stages, of the
mucous membrane flap from the lower lip.

If the vermilion border missing is situate on the outer third of the lip, then
the mucous membrane flap from the lower will have its base near the corner of
the mouth. But if the missing portion of the vermilion border is in the central
portion of the upper lip, a flap is conveniently turned up, in a vertical direction,
from the centre of the lower lip, with its base towards the free margin of the
lip.

In this latter event, it is necessary to stitch the two lips together while
union is taking place and before the pedicle is divided. For the details of such
operation see Case 184, p. 150,

82 PLASTIC SURGERY

A few other general points about upper lips are worthy of mention. Com-
plete loss of the upper lip does not occur, in my experience, without the loss
of the pre-maxilla, and quite half the difficulty of forming a satisfactory upper
lip in a complete loss is to be found in the difficulty of restoring the bony contour
by means of a dental appliance. There are usually very few teeth left in the
upper jaw on which to carry a satisfactory prosthesis ; in addition, one fre-
quently makes a mistake in making an upper lip with flaps insufficiently long,
and consequently there is a tightening and flatness, and the denture becomes
very liable to be pressed on and easily displaced. Another of the mistakes
that I have perforce fallen into is that one did not at first realise that the
prominence of the central portion of the upper lip was due not entirely to the
pre-maxilla, but to what I describe as the suspension of the upper lip from
the columella of the nose. The upper lip hangs like a curtain from the
columella. With one's fingers in the vestibules of the nose, gripping the
columella, one finds that the upper lip is suspended by that portion of the nose.
Looking at a normal upper lip from the side, one is aware that it runs well up
into the columella, whereas in actual practice the majority of the new upper
lips do not present this suspension from and incorporation into the nose ;
they seem to run straight across from one ala to the other in an abnormal
manner. Frequently, of course, this condition results from the accom-
panying loss of the columella and anterior nasal spine ; but, in repairing
the upper lip, the anatomical attachments that I have mentioned should be
aimed at.

I am indebted to Professor Henry Tonks for pointing out to me the defects
in the upper lip from this point of view, especially from the loss of the pre-
maxillary prominence, and, on thinking the matter over, the suspension of
the upper lip from the columella presented itself to me.

It is quite reasonable, as mentioned above, to turn a portion of the lower
lip into the upper; but when this process is overdone, the result is most
unpleasant. The greatest care must be exercised in this manoeuvre to see
that ugly deformity of the angle of the mouth is not produced.

In comparing it with the lower lip repair, it would seem to me that
the shortening of the upper lip is a very much greater defect than a similar
shortening of the lower. In a few words, it is quite possible to sew up a lower
lip which has lost nearly a third of its bulk without causing either a serious
functional or aesthetic deformity, whereas a similar loss of the upper lip cannot
be produced without very serious impairment of function, accompanied by
a most unpleasant effect, and it is probably for this reason that, in my
experience, the formation of the upper lip is more difficult than that of the
lower.

INJURIES OF THE UPPER LIP 83

ILLUSTRATIVE CASES

Those that I have chosen to demonstrate loss of the upper lip and its repair
have been grouped in the order of decreasing severity ; thus the first few are
examples of complete loss, whereas the last are of minor injury of the lip.

Total loss of the upper lip, as I have already stated, is not met with without
the accompanying loss of the pre-maxilla, either in part or as a whole. Fre-
quently these severe injuries of the upper lip involve the lower portion of the
nose, and in some cases the whole of the nose, as well as the pre-maxillary
and central two-thirds of the upper lip, has been destroyed by one projectile.

The problem of the repair is to a large extent dependent on this loss
of the pre-maxilla. I have divided the severe upper lip injuries into those
accompanied and those unaccompanied by loss of the bony structure. It
is with the bony loss type of lip that the aid of the dental surgeon must be
urgently invoked. In all cases a prosthesis should be prepared, which will
ensure that the new lip is efficiently supported from underneath, and at the
same time that the incisions of the mucous membrane do not lead to cicatricial
contraction of the upper sulcus. It should be designed so as to have as perfect
a fit as possible, and, if necessary, it may be supported from the lower teeth
or even from a lower denture. This dental appliance must be so made as
to ensure that the new lip is of sufficient size. After the under-lining of the
new lip is satisfactorily made of mucous membrane or skin turned inwards,
very little if any contraction need be allowed for, but if any raw areas on
the under-surfaces of the lip are exposed to the buccal secretions, ulceration
will cause severe contraction. No upper lip should, therefore, be designed
which does not include its most important element, the mucous lining. In this
class of case, the following is a good example :

84 PLASTIC SURGERY

CASE 106

This R.A.M.C. Orderly was wounded by a shell fragment on 28.4.16, and
admitted for plastic treatment on 27.6.16, two months after he actually received
his injury. His condition was most repulsive complete loss of the upper lip was
accompanied by total loss of the pre-maxilla and by destruction of the anterior
portion of the floor of the nose, and of the adjacent walls of left antrum. The nose
was considerably deformed and dragged downwards in the healing process. A
satisfactory dental appliance having been made by Captain L. A. B. King, L.D.S.,
and his staff, the patient was operated upon under general anaesthesia.

Preliminary laryngotomy was performed by the Butlin method and the anaesthetic
given through this opening. The pharynx was packed off so that blood did not
enter the lower air passage. The main design of the operation is shown in diagram 107,
which needs little amplification. The main part of the upper lip was made by a
descending lateral nasal flap which was swung from the right side across to the left.
This flap included muscle and mucous membrane, and, in order to lengthen it, the
knife was carried through the corner of the mouth in a parallel direction to the first
cut. This flap reached about two-thirds of the way across the lip. On the left side,
the broad flap, as shown in the diagram, was outlined and swung up to meet its
fellow. This flap was broader at its base than at its extremity ; it also included
mucous membrane. In regard to the nose, the left ala, which was tied down to the
remains of the nasal floor, was elevated, and re-sutured into position. On the whole
the result of this operation was fairly satisfactory; the mouth, however, was small
and the upper lip did not present very good lines, nor did the muco-cutaneous
junctions show at all as a vermilion border. The manoeuvre of pulling over the right
flap towards the left had narrowed the mouth. Subsequent correcting operations
were performed on various dates. Under a local anaesthesia, the right corner of the
mouth was enlarged by a simple incision and the pulling out of the mucous mem-
brane. On 16.1.17 examination notes read that deep scars were radiating from the
left angle of the mouth into the lower lip, while other scars were present at the
junction of the flaps making the new upper lip, and in the left cheek. All these scars
were more pronounced than usual. Under general anaesthesia, they were dissected out
that in the upper lip was dissected out in a diamond-shaped fashion, there being
a slight notch at this point, and sewn up vertically to give extra depth. This
manoeuvre was quite satisfactory, but not quite sufficiently radical. The notch in the
lower lip was rearranged by swinging flaps, as shown in fig. 110. A small excision
was carried out just above the right angle of the mouth to raise the same, while the
ala of the left nostril was carried farther to the left. All sutures were carefully made
with interrupted horsehair. The results of these corrections were satisfactory on the
whole, except that the scar lines were still very prominent. Three months later,
17.4.17, the mucous membrane of the upper lip was brought farther out to become
more prominent, and one of the scars of the lower lip was re-excised and sewn up
with subcutaneous catgut. The scar-line thus produced was again unsatisfactory, and
it was apparent that this man's skin, though it always united well by primary union,
was of an unusual character. The reason may be forthcoming in the fact that there
is a considerable amount of acne present. The later history of these scars is inter-
esting, as they are apparently becoming more obliterated than usual by tiny bridges
of skin growing across, and already one of the scars is invisible.

This case has opened up the question of the histology of good scar production.

The two small palatal perforations were closed by mucous membrane flaps on
7.6.17; one of the flaps partially broke down. In order to fill up the depression
in the left cheek, the lateral scar, shown in fig. 1C 9, was excised, and the skin under-
cut in its neighbourhood and free fat-graft from the subcutaneous tissue of the
abdominal wall inserted; the skin was sewn up with subcutaneous horsehair.

Like many other fat-graft operations in this region, the union was primary and it

INJURIES OF THE UPPER LIP

was not until a week after the stitches were out that a slight oozing of fat occurred
followed by some suppuration. This condition was cleared up with Biers' cupping, and
th.3 final result is satisfactory. Even after the first operation, it was a great satisfaction
to hear this man speak with his native brogue again. Before operation he was a man
who was so sensitive about his appearance that he did not like mixing with his fellow
patients or with the outside public.

Fio. 105. On admission.

FIG. 100. Prosthesis in position. (Discoloration
due to Iodine.)

Fio. 107. The (laps. Right, descending. Left, ascending.

Fio. 108. Suture.

PLASTIC SURGERY

Fid. 109. First result.

Fio. 110. Upper and lower lip corrections.
Incisions.

Fio. 111. Suture.

FIG. 112. Final.

INJURIES OF THE UPPER LIP

CASE 525

An example of total loss of upper lip. This man on admission to a Base hospital in
France still possessed an upper lip, but it was in a damaged and semi-gangrenous condition,
and, in spite of the utmost care, the whole thing sloughed, leaving the condition shown in
fig. 113. Partial attempt to relieve the deformity had been made prior to admission to my
service, the result of which procedure is shown in fig. 114. The mouth is very contracted
and the lower lip pouted. The new upper lip is insufficient and short, while the whole nose
is lengthened and depressed. It was decided to reconstruct the wound and to replace
the nose in its normal position.

Operation, 23.7.18. Scar tissue in the centre of the new upper lip was excised, as was
that around the attachment of the nose. The stumps of the upper lip were allowed to
retract into their normal position, in which situation the mucous membrane was brought
out and sewn to the skin. No attempt was made to repair the lip at this stage. The nose
was gradually freed until it could be raised into its position. The only blood supply re-
maining to the nose being a small bridge in its upper part, this undercutting and raising had
to be done with the greatest of patience and care. The alae were brought together beneath
the tip and the nose sutured. This was a very risky procedure, and I was more than thankful
for its satisfactory result.

It now remained to repair the upper lip uncomplicated by the false attachment of the
nose. Elaborate diagrams by Mr. Hornswick of this operation are included, and show the
developments of diagrammatic illustration for this form of record in an exceedingly difficult
case.

Haps A and B from the left and right cheeks respectively were turned skin-surface
inwards over a large dental appliance fitted by Captain W. Kelsey Fry, M.C., R.A.M.C. ;
they were sutured together. The mucous membrane off the stumps of the upper lip was
cut into two flaps (C and D), one on each side, and by advancement came to lie along the
lower borders of A and B, where they were sutured, not only to each other, but also to A
and B. These mucous membrane flaps were broad enough to complete the lower border
and to curl round for the vermilion edge of the new lip.

FIG. 113.

Fid. 114.

FIG. 115.

FIG. 113. Total loss of upper lip and underlying bone. (Photo taken in France.)

FIGS. 1 14, 1 15. Condition on admission. These show the indifferent result of making a lip by advancement
methods. Both the lips and the nose are backwardly displaced. The mouth is contracted, and the lower lip is
pouted. [Note : These defects have, in this case, been accentuated by the failure of part of the flaps to survive.]

PLASTIC SURGERY

The skin covering was the next problem, and
double ascending flaps A' B' were taken from the
lateral aspects of the chin and sutured together over
the inturned flaps A and B. To their lower borders
were sutured the lower free borders of the mucous
membrane flaps C and D.

The secondary closure did not present any great
difficulties. The most anxious part of the operation
was flap A', which had a great deal of scar tissue in
it. In fact, the only clear bit of skin was a minute
portion on its lower border. I had great fears of
losing the whole flap. However, the blood supply
returned and was maintained satisfactorily. Apart
from some slight breaking down of the suture line
A' B', the healing process was satisfactory. The
columella had been brought out, lengthened and
sutured in the middle of the upper lip : this wants
rearrangement, as is evidenced from the photograph
which merely represents the present stage of the
repair.

Fio. 116. Diagram of the ex-
cision of scar tissue, practised
to bring about replacement of
the nose upwards and forwards,
and to allow the corners of the
mouth to separate.

Fio. 117. Fio. 118.

l'io. 117. Shows the result of putting into practice the author's principle of replacing the remnants into
normal position. Skin is sewn to mucous membrane so that no raw area occurs. An upper prosthesis is now
fitted, replacing the lost hard tissues.

Fio. 118. Profile of same stage, showing the vast improvement in the nose. No apparatus was employed
to retain the nose.

FIG. 1 1 9. The incisions.

Fio. 120. The flaps.

Fio. 121. Suture of the interned
and mucous flaps.

Fio. 122. Final suture. Fio. 123. Sectional view.

FIGS. 119123. A and B = cheek flaps, inverted to form the posterior epithelial surface of the new lip.

C and D = mucous membrane, advanced flaps taken from the lip stumps to form the mucous membrane
lower border of the new lip.

A' and B' = ascending cheek-chin flaps to form the outside skin covering to the whole. The raw areas caused
by the cutting of these two flaps is closed by approximation.

FIG. 124.

Fid. 125.

Fio. 124. Result of the six-flap plastic operation portrayed in the diagrams. A permanent upper prosthesis
; fitted.

FIG. 125. Profile of result. Note the pi
apparatus representing the missing maxilla.

S FIG 125. Profile of result. Note the prominence of the new upper lip, which is supported by a vulcanite

PLASTIC SURGERY

CASE 7

In the next case also one of similar but less destruction of upper lip the prc-maxilla
was destroyed ; but a small and valuable piece of upper lip remained at the left angle (a
point not evident in fig. 126, taken a fortnight after the wound). Fig. 127 shows the healed
condition, a remarkable improvement. The lower lip has become almost normal, and
little scarring has resulted, but the remains of the left upper lip have become attached
and drawn upwards.

Primary suture was expressly avoided, and the main repair of the upper lip^was per-
formed over an effective dental support ten weeks after the wound. Lateral nasal flaps
were used on both sides (fig. 128), and by advancement of the mucosa of the left side, it
was made to cover half the under aspect of the new lip, and to line not only the left but

FIG. 120. On admission twelve days after injury.

Fio. 127. The healed condition.

part of the right side. Ihe lining was completed by advancing a descending flap of mucous
membrane from the right cheek near the angle of the mouth. The result is shown in fig. 130.

A month later, a more extensive operation was made, to level the mouth and to adjust
the relation of mouth to nose : the lower nose was freed from bone, and swung to the right.
and the upper lip to the left, both being sutured in their new position. Though the nose
pointed somewhat rightward, yet, viewed with the mouth, it gives a more symmetrical face.

A right chin flap was then swung up to the upper lip, to deepen it, and was lined by
an advancement of mucosa. As usual, this flap depressed the angle of the mouth slightly,
a defect not hard to overcome.

An effort was first made to raise the angle by a horizontal incision through all thick-
nesses of the lip opposite the seat of the depression, sewn up vertically. This resulted
in a partial improvement of the deformity, and is a method not often indicated. Two and
a half months' rest was given, during which massage and movements were undertaken.
The diagram, fig. 13, shows the method of curing the depression of the angle of the mouth,
and is in reality a partial replacement of the original flap. A satisfactory result of this is
shown in the final photograph. All scars were fading rapidly when the patient was dis-
charged, and the total eflect was gratifying.

INJURIES OF THE UPPER LIP

Fio. 128. Incisions. Fid. 129. Suture.

The clotted area represents a mucous membrane flap.

Fid. 130. First result.

FIG. 131. Shows method of curing a depressed angle
of mouth. Xote: this condition had occurred owing to
an operation referred to in the text but not illustrated.

Flo. 132. Final result.

92 PLASTIC SURGERY

CASE 21

This case is one of a very similar character to the last, and about the same amount
of the upper lip remained after the injury. The denture fitted to represent the pre-maxilla
is shown in the accompanying figure, No. 133. This case, treated on similar lines to
No. 17, has not shown the same satisfactory results. The lip was made too short, and
considerable difficulties were experienced in fitting a satisfactory denture after the new
lip had been made. The probable reason why this case has not done so well as the
previous one is that there was less mucous membrane remaining after the injury.
Trouble was also experienced in retaining the denture, and adhesions formed between
the new lip and the remains of the upper jaw. There were also adhesions to contend with
between the cheek and the lower jaw, which made the dental treatment more difficult.
In this case it would have been wiser to use a skin flap, turned inwards, to line the new
lip. It will be noted that an ascending flap was not available on the right side on
account of the scar tissue there. A modified descending flap was therefore used on both
sides, and that on the right had a bend in it which turned it in to an advancing flap.
The patient had erysipelas about six weeks after receiving his wound. The first
operation was undertaken about three months after the date of his injury. This was
performed on 9.10.16, when adhesions tying down the nose were divided and scar tissue
excised ; about in. of the red margin on the left side was intact. A flap, including this
portion of the lip as its base, was cut from the left side of the nose and brought down
under the nose. A skin and tissue flap from the right side, with its base opposite the
mouth, was cut and straightened out to meet the corresponding flap from the other side.
A mucous flap from the inside of the right cheek was cut with its base on the lower lip and
curled around part of the new upper lip. A hare-lip condition was thus left, but it was
not deemed advisable to form a double mucous flap. No relaxation sutures were used,
but several silk-worm-gut deep stitches were inserted. There appears to be some tension.

Fio. 133. Denture with artificial pre-maxilla.

Examination of the condition after this operation showed that the new mucous lining
to right half of upper lip was satisfactory. There was a U-shaped gap in the middle of
the upper lip, and no columella. On 2.11.16 an excision of the scar was made round
the U, and prolongation of the incisions laterally on the left through the angle of the mouth
and through the line \ in. above it, and through all the layers of the lip ; this was brought
over to the right and sutured into position with catgut and horsehair sutures. The
columella of the nose was formed by cutting out the anterior portion of the remains of
the septum ; in this upper part the knife was entered behind and brought forward towards
the tip, and this made a satisfactory columella, which was inserted into the incision of the
upper lip. In spite of careful suturing the left angle of the mouth drooped. Adhesions
were divided between the lower jaw and mucous membrane on the right " side. The
attachmsnt of the new columella broke down, but otherwise the results are fairly satis-

INJURIES OF THE UPPER LIP

factory. Great difficulties were experienced in keeping the lip well supported with the
denture, and adhesions reformed. I think the flap on the right in the original operation
should have been taken right through to the mucous membrane instead of making two
flaps, one of skin and muscle and one of mucous membrane. The appearance after these

Fia. 1 34. On admission two months after
injury.

FIG. 135. Healed. The dental appliance
displaced to show its composition. Note
the scar on right cheek referred to in text.

FIQ. 130. Flaps. (A mucous membrane flap not outlined.)

Diagrams by H. T.

Fio. 137. Suture.

PLASTIC SURGERY

FIG. 138. Result first two operations.
Note droop of angle : denture not in place.

FIG. 139. Flap to raise angle.

FIG. 140. Suture.

FIG. 141. Result of this. Denture fitted.

INJURIES OF THE UPPER LIP

two operations is shown in the accompanying fig. 138. The falling in of the lip without
the denture and the droop of the left corner of the mouth is well seen. A small operation
was performed on 13.3.17 in order to raise the corner of the mouth, and this was
successful in carrying out this object. In order to fit the denture in, Captain Rumsey
divided the upper sulcus.

Scar tissue formation, however, gradually filled up this sulcus, and prevented the
further wearing of the denture. In addition, trismus was present, which, on investigation,
was found to be due to a band of scar tissue from upper to lower jaw on the right side
of the cheek, and which had formed as a result (a) of the injury, and (b) of the intra-oral
operations.

On 9.1 .18 an operation to remedy these defects was undertaken, the principle being
that of the Esser epithelial inlay.

To repair the upper sulcus, an incision was made at the upper border of the upper
lip and carried down to the mucous surface. Care was taken to excise a portion of the
scar band above mentioned. The cavity produced was of some size, and extended from
just to the right of the scar band to where the sulcus became normal again on the left
side of the mouth. The usual Stent model and skin graft was inserted.

A similar procedure was carried out along the lower sulcus. The models were taken
out on the tenth day through intra-buccal incisions.

Considerable difficulty was experienced in keeping the newly epithelialised cavities
patent, and, as the upper sulcus was the more important of the two, it received more
attention. The successful establishment of this sulcus was to a great extent due to the
careful efforts of Captain Kelsey Fry, M.C., R.A.M.C. The lower sulcus operation was
not so successful. It would have been better to have done this at a separate operation.

The upper lip is now maintained in a forward position.

On 4.6.18 the columella was re-made in a manner similar to the first procedure
but of a greater length, so that the tip of the nose was even .pushed up a little bit by this
new columella.

FIG. 142.

Final after Esser inlays and columella operation.

PLASTIC SURGERY

CASE 151

This is one of the Australian patients who have been under my care. He was wounded
in the later battle of the Somme, and came to me at Aldershot, six days after receiving
his wound on 20.10.16.

The condition, when healed, showed a considerable loss of the pre-maxilla, and the
floor of the nose in its anterior part, while the soft tissue loss consisted of about two-thirds
of the upper lip, together with the left ala, columella, and anterior portion of the septum
of the nose. The tip of the nose was dragged down by fibrous tissue and loss of support.

The first operation was undertaken on March 3rd, 1917. It was of an orthodox
type, and consisted of two lateral nasal descending flaps, A B and A B. These were
whole-thickness flaps which contained the mucous membrane. That on the left proved
to be satisfactory as it contained the remaining normal part of the upper lip, but that
on the right contained much scar tissue, and the result was not gratifying.

Diagrams representing the next stage are appended, and the details of this operation
follow :

The main principles of it were, in regard to the nose, that two higher lateral nasal
flaps were tucked in beneath the alse to allow the tip of the nose to rise. And in regard
to the right half of the lip, it was deepened and reconstituted by turning downwards a
flap of skin as a lining and the superimposition of a long pedicled bridge flap from the
left cheek and chin.

When this case was transferred under Lieutenant-Colonel Newland, D.S.O., A.A.M.C.,
he very kindly allowed me to continue the treatment, and I have had the encourage-
ment of his advice and assistance in this somewhat long and difficult procedure. The
case is not yet completed, but is well in hand, and the final result should repay one for
the efforts and length of time expended on the case.

FlO. 144. Six days after wound.

FIG. 145, When healed.

FIG. J4G. Side view.
Same stage.

INJURIES OF THE UPPER LIP

Copy of Case Sheet Notes given below :

10.3.17. Operation. An upper lip was formed by cutting a flap from right cheek
and swinging it down to meet a similar one from the left ; but this latter contained normal
mucous membrane.

FIG. 147. Showing descending flaps.

Fia. 148. Suture.

Fio. 149. Result of lirst operation.

The tip of the nose was freed and nasal
passages restored. Tissue representing remains
of columella was dissected up and sutured to
middle line of lip. Small mucous flap was
turned up from lower lip to form red line for
remainder of upper lip. Deep catgut sutures
were used, and artificial plate was inserted
to support new lip. Nasal plugs, supported
by vulcanite head piece, were adjusted with the
object of holding tip of the nose in position.

20.9.17. Condition. Previous operation
for upper lip moderately successful. Con-
siderable deficiency middle of right half of
upper lip. Deformity of nose partially cor-
rected, but columella has not become attached.

20.9.17. Operation. For correction of
upper lip. Owing to the scarred and pustular
condition of the face, no flap was available
from the right for the lip. In order further to
raise the right ala, a small flap was taken
from the lateral aspect of the nose and swung
down beneath the ala. A similar flap was
swung down on left side beneath the remains
of the left ala and sutured to the top of the
upper lip. This enabled the tip of the nose to
be considerably raised.

PLASTIC SURGERY

A skin-flap of the existing right portion of the upper lip was turned downwards,
with its skin surface inwards, and into this raw area was laid the end of an ascending
pedicle bridge flap with its base opposite the upper lip on the left side. The area from
which this flap was taken was completely sewn up. The grafted end of this flap obtained
linn union into the upper lip and the pedicle of the flap was cut under local amrsthetic on
October 13th. No attempt at replacing the pedicle was made, and it was cut short at its
base. This free lump of skin was left sticking out from the lip for possible future use in
the nose. Massage was employed from the first day.

24.10.17. Condition satisfactory. It is possible to train this flap of skin upwards
towards the nose for later attachment there.

Operation (Major Gillies with Lieutenant-Colonel Ncwland). The cut pedicle
referred to above had rounded itself off into what looked like a tip of a nose lying on the

FIG. 1 50. 1 ncision for inverting portion of lip to
complete the lining

FIG. 151. Diagram showing bridge pedicle flap A.
Terminal portion only used.

upper lip. It was partially re-detached, and sewn up underneath the columella and left
ala. Lip support was made by Captain Russell, A.D.C.

4.2.18. Operation (Major Gillies with Lieutenant-Colonel Newland). Further de-
tachment from lip and completion of right half of columella.

16.5.18. Operation (Major Gillies with Lieutenant-Colonel Newland). The left side
of columella and lining of nostril was made, and the remainder of flap was used to form
the left ala.

20.12.18. Operation (Major Gillies). Cartilage taken from rib and inserted through
the columella in two pieces, one down the columella and one up the bridge. The bridge
piece was fixed at its upper end to the existing nasal cartilage through a separate incision
made across the bridge at a spot where an existing scar was present. Result satisfactory.
Hut owing to the pustular condition of the face, which has continued despite special treat-
ment, a slight infection of the cartilage occurred. No material damage, however, eventuated,
and the sinus rapidly healed.

INJURIES OF THE UPPER LIP

FIG. 152. The pedicle cut near the base and
allowed to curl up.

FIG. 153. Utilising the pedicle for nasal
restoration.

FIG. 154. Result after further adjustment and
cartilage implant to nose and columella.

FIG. 155. Ditto, side view.

100

PLASTIC SURGERY

CASE 245

This sergeant was admitted in a healed condition. There was partial loss of the
pre-maxilla, and loss of more than half of the upper lip, together with an iigly twisting
of the nose, and depression of the tip. This patient was operated on four months after
the receipt of his wound. It will be noticed in the appended operation notes that he
developed bronchitis after the operation. Therefore the failure to get a really satis-
factory result may well be put down to this trouble, as the coughing which followed
undoubtedly prejudiced the union of the flaps. Three weeks after this operation the
patient, when at a Convalescent Hospital, developed septic pncuziionia, from which he
recovered slowly.

Although the record number is a late one, this was one of my early cases, and it brought
home to me the necessity for some different form of anaesthesia from that usually employed
in mouth cases, and in those of chin and upper lip in particular. In the pages on
anaesthesia this matter is fully dealt with. A fairly satisfactory result was obtained
from an aesthetic point of view, and, functionally, it was good. It should be remarked,

FIG. 150. Condition on admission healed.
Loss o right half of lip.

however, that a secondary deformity of the lower lip was produced. Since the date on
which the last illustration, fig. 161, was taken, this sergeant has done a year's duty witli
Home troops. Details of operations on this case follow :

22.6.16. Operation. Formation of upper lip. The flap of skin and mucous mem-
brane representing the remains of the upper lip was dissected out from left nostril, and
by an incision parallel to the lip margin the flap was brought over towards the right to
meet two flaps from the right side which were separated by a piece of excised scar. The
lower of these flaps was a small one, containing the angle of the mouth. Result : The
dental shield for the new lip which had been made was not tolerated by the patient, who
had some bronchitis after the operation. A certain amount of breaking down occurred
at the junction, and owing to the absence of intra-oral apparatus the new lip became
adherent to the alveolus of the upper jaw. Apparatus for distending of lip after division

INJURIES OF THE UPPER LIP

101

of adhesions is shown in photograph. Three minor operations were carried out to widen
the mouth and to produce a mucous membrane line to the upper lip. Functionally the
result was good, cosmctically there was still an ugly arrangement of the lower lip. Dis-
charged for duty, 3.3.17.

FIG. 157. Advancing flaps.

FIG. 1 58. Result, flat lip.

FIG. 159. Suture.

FIG. 100. Attempt to bring forward and stretch
new lip.

FIG. 161. Result of later operations. Denture
fitted. Note : the lip is still flat and has no
central prominence. The lower lip is pouting.

102

PLASTIC SURGERY

CASE 4.3

These cases of upper lip arc dealt with here in order of decreasing severity, and this
one shows a loss which is less than the previous one. The result is correspondingly better.
In addition to an upper lip injury, there was a slight deformity of the lower, combined
with loss of the angle. The condition within forty-eight hours of the wound is shown in
the first illustration, and I am indebted to Major Valadier, C.M.G., for allowing me
to have the early wound record of this case. The second photograph is an illustration of
the result of an early suture, performed by Major Valadier in France. The mucous mem-
brane of the upper lip was preserved by sewing it to the chin, and the tag on the cheek
was sutured into place, the mucous membrane being also brought out to the skin edge.
This system undoubtedly helps the later plastic repair as it decreases the scar tissue.
Accompanying this injury was a very large loss of bone in the lower jaw, involving the
angle and adjacent portions of the mandible ; there was also a considerable loss of bone
in the superior maxilla and alveolar process. The further method of repair is illustrated
in the accompanying diagrams, and consisted in a whole thickness flap swung down from
the left lateral nasal region to meet the remains of the upper lip which was split to
receive it, the lower portion of the split containing the vermilion border being made to
extend along the new portion of lip.

To complete the mucous membrane, that of the lower lip was swung round the corner
to the upper, a slight advancing of the flap marked " B " enabled the lower lip to be satis-
factorily corrected. No further operations on the lip were undertaken, and a satisfactoiy
result was produced. Discharged to duty.

Kio. 162. Shortly after wound. Taken in France (Valadier).

INJURIES OF THE UPPER LIP

103

FIG. 163. On admission healed.

Fio. 104. Descending and ascending whols
thickness flaps.

FIG. 105. Suture.

Fia. 100. Result.

Fio. 107. Same later.

104

PLASTIC SURGERY

FIG. 108. Prior to admission to Queen's Hospital.

FIG. 109. On admission healed. Part loss of
upper lip, nose, and cheek.

CASE 324

This is included in this series as an example of the use of a temporal and scalp flap for
the external covering of a portion of the upper lip. One half of the upper lip remained on
the left side, the right half being completely absent, as well as a large portion of the cheek,
nose, and right superior maxilla ; there was an accompanying fracture of the right mandible,

FlO. 170. A and B are interned epithelial FIG. 171. E the temporal flap

fla P 8 - sutured to form the covering. Fl(J , - 2 _ Result after return of temporal

flap. Note deficiency of upper lip, and of
contour.

INJURIES OF THE UPPER LIP

105

with deformity of contour. The patient was transferred to this hospital eleven months after
being wounded. The mandible had united by approximation. The first operation was
undertaken as a combined lip, nose, and cheek plastic. In fig. 170, flaps A and B were
turned skin-surface inwards to form a lining for the right ala and right half of the upper
lip. The latter was sutured to the mucous membrane on the back of B, which is the re-
maining portion of the upper lip. Over the raw area thus produced a shaped flap, E, from
the right temporal region was sutured into position on 24.9.17. Three weeks later the
pedicle of flap E was returned. This was done for me by Captain C. F. Rumsey, R.A.M.C.,
and the result of these two operations is shown in the next fig. 172. Considerable time was
allowed to elapse during which cpilation by X-rays of the hairy surface of the nose was
undertaken. As the new upper lip was too shallow, it was decided to turn skin surface
inwards a portion of this new flap and to bring up an ascending flap from the right side
of the chin, and at the same time a flap of mucous membrane was brought up from the
lower lip for a vermilion border.

Rhinoplasty was performed on 18.11. 18, and at this operation the pedicle of the mucous
membrane flap of the previous operation was divided to form the right corner of the mouth.
When the pedicle of the rhinoplasty was returned a depressed scar, caused by the ascending
lip-flap, was excised, and a notch in the new upper lip was corrected by a Rose operation
(Captain Ferris N. Smith, R.A.M.C.). Cartilage was inserted over the right mandible and
further scars excised on 3.2.19. Present result is shown.

Fro. 173. 1. Deepening the lip by an ascend-
ing chin flap.

2. Mucous membrane flap from lower to upper
lip.

3. Preliminary to radical nasal reconstruction.

FIG. 174. Final result of lip, cheek, and nose
plastics. Note the improved cheek contour by
cartilage graft.

10(5

PLASTIC SURGERY

CASE 143

There arc several interesting features about this case which need defining. I have
included it in the " Upper Lips," as I have learned a principle in connection with its repair.
It is also one of my first cases. I designed the upper lip operation with two superimposed
flaps so as to produce depth at the spot where the hare-lip type of notch was present.
Tin- two flaps were made to overlap after the replacement of the vermilion border to
its normal level. A good deal was allowed for contraction, and the right-hand flap was
cut in such a \\ay as to produce considerable drooping of the right half of the upper lip.

Fio. 1 75. Hnre-lip type of deformity with
loss of substance.

FIG. 1 70. Scar excision.

Fio. 177. Scheme of the flaps.

FIG. 1 "8. Diagram of
overlapping flaps to pro-
duce depth.

FIG. 179. Result of Jip operation. Xote
redundancy.

INJURIES OF THE UPPER LIP

107

There was no important loss of the mucous membrane lining of the upper lip, and
consequently the retraction and contraction following the operation was very limited.
Therefore I had to excise portions of this flap until the correct level of the vermilion
border was obtained. Another principle involved in this repair was to use pointed
overlapping flaps to produce depth.

In regard to the nose plastic, the scar running down the right aspect of the nose and
across the bridge was excised ; the nose was raised and the right ala was sewn down at a
lower and normal level. This was done on the occasion of the second operation. A month
later a bone graft was taken from the left tibia and inserted into the bridge of the nose to
raise it. The bone was cut with the Albce double electric saw. The periosteum was not
included. In regard to the fixation, the periosteum over the glabella region was raised
and a groove made into the bone into which the upper end of the graft was fixed. The
distal end of the graft was pushed down subcutaneously into a cavity made for it nearly
as far as the tip of the nose. A misfortune occurred
at the end of this operation, as the patient vomited
freely before the graft was quite fixed in position
and the asepsis of the field of operation was thereby
violated. A slight suppuration followed, but this
practically cleared up except for an occasional drop
of pus which could be squeezed out. Later a small
portion necrosed and was taken away from near the
left internal canthus. The skin then healed up
satisfactorily, but no bony union occurred with the
frontal bone. When last examined, the graft was
still in position, but is presumably in process of
being replaced by fibrous tissue, and the bridge had
not been sufficiently raised. It was decided, there-
fore, to insert some cartilage, which was done
through an incision over the tip of the nose and
into the columella. A piece of costal cartilage
was then superimposed over the remains of the
bone graft. When in position, the extremity of the
cartilage was bent into the tissues of the columella
to support the tip. The incision over the bridge
of the nose was likewise reopened at this operation,
and an attempt was made to get union with the
frontal bone by turning down an osteo-periostal
flap beneath the original bone graft. Whether
bony union occurred or not was not established as
the patient was discharged to duty, but the cartilage operation was satisfactory in every
way except at the bridge of the nose, where it became slightly displaced. As far as the
left eyelids are concerned, mal-union of the upper lid had occurred, completely obliterating
the palpebral fissure. This upper lid was freed by a mesial descending incision, and the
lid was sewn up at a higher level. The lower lid was also freed by carrying a curved
incision from the inner angle outwards beneath the lower lid, and this also was sewn at a
higher and more mesial position. A moderate amount of vision remained in the left
eye, and considerable benefit accrued to the patient by reopening his palpebral fissure
both in regard to appearance and function. The final result is shown in fig. ISO. 1

FIG. 1 80. Excision of excess lip and nose and
eyelid plastics.

1 This is the only case in which I have used bone alone for raising the bridge of the nose. Compare
this case with case 252, p. 228.

108 PLASTIC SURGERY

CASE 48

Another type of upper lip is shown in the following case. The patient was received
after many plastic operations in the condition shown in fig. 181, and there was a large muss
of scar tissue making up the substance of the upper lip. There was a blob of mucous
membrane at the left corner, which was utilised by extending it along to the right. The
patient was edentulous. This also was one of my early cases. The result of the first
operation is shown in the second picture. The main feature of this operation was the
excision of the scar which was present in the upper lip and around the depressed angle of
the mouth. This left a very large gap to be filled in, which difficulty was met by a descend-
ing flap from the left cheek. The flap united satisfactorily in its new position, but the
suture of the cheek after the removal of the flap broke down somewhat badly, as is evident
in the photograph. A subsequent operation was performed to widen the mouth, but this
had to be curtailed owing to anaesthetic difficulties and blood collecting in the patient's
throat. The scar of the face was excised, but again this broke down. I decided, therefore,
to give him a prolonged course of X-ray treatment, massage and special vaccine made
from culture of his own micro-organisms. An attempt was again made to excise the ugly
scar on the left cheek; but, as on previous occasions, this broke down, but only partially.
The total result was a very considerable improvement in appearance and function.

INJURIES OF THE UPPER LIP

109

FIG. 181. Large portion of upper lip occupied by
keloidal scar.

FIG. 182. Note breaking down of secondary
suture area, after the descending lateral nasal flap
had been brought down to upper lip.

Fio. 183. Final result.

no PLASTIC SURGERY

CASE 242

This case shows an injury of the lip without serious bony damage, with less of teetli
only. The loss of the lip is a little more than a third, but the loss of the skin surface is
greater than that of the mucous membrane. The condition when it had healed is shown
in the next illustration, which, however, does not adequately represent the amount of scar
tissue to be excised. The morphology of the original wound was therefore reproduced,
but to a slightly diminished extent. The diagram illustrates the amount of scar tissue
which had to be excised and the flaps used to repair it. It should be remarked that
the vermilion border b?longing to the right-hand flap was separated from this flap and
advanced on to the lower border of the left-hand flap, so that the skin-joint was not at
the same site as that of the mucous membrane. In criticising the result of this procedure,
which was, in general terms, a descending flap and partly an advancement method, it
will be observed that the upper lip slightly overhangs the lower at the left-hand corner
of the mouth, and the lower lip is somewhat pushed out of position thereby. This, I
think, is due to the advancement of the flap, and bears out my contention that the
upper lip will stand little in the way of shortening by advancement flaps.

INJURIES OF THE UPPER LIP

111

FIG. 1 84. One week after injury.

FIG. 185. ftesult. Note the overlapping at the
angle produced by an " advancement " flap.
This is amenable to secondary correction, but
only the one operation was performed in this
case.

FIG. ISO. Excision and Incision. No mucous
membrane was excised, as might bo inferred from
diagram.

FIG. 187. Suture. Note skin and mucous
membrane suture at different sites.

112 PLASTIC SURGERY

CASE 177

This private was received after a gunshot wound which had destroyed half the skin
of the upper lip and one-third of the veimilion border. He was admitted into the depait-
msnt in the scarred and healed condition as shown in fig. 188, and had already received
two or three plastic operations on the lip. The amount of loss of tissue is well shown in
the diagram, representing the healthy tissue remaining after excision of the scar tissue
in the upper lip. The scar tissue in the cheek was similarly excised. Under chlorofoim
oxygen anaesthesia, in the sitting position, the scar tissue in the upper lip was excised com-
pletely, except where it had involved the mucous membrane on the posterior suifacc. A
large ascending flap from the cheek was taken to fill up this gap, as illustrated in dia-
gram 189, and the mucous membrane surfaces readjusted. The healing was by first
intention, but the result of the operation was to depress the corner of the mouth. 1 This
was due to the base of the pedicle, flap " A" being too wide. Another secondary deformity
occurred as a result of this operation on 3.4.17 in that, in drawing the two cut surfaces of
the mucous membrane together, an unpleasant pouting of the corner of the mouth was
produced. On 3.9.17 operation was again performed, the objects of which were to restore
the left angle of the mouth to its proper level, to evert the mucous membrane and
to attempt to thicken the border of the lip. In the first place, a reverse flap to that
taken at the original operation was swung from the upper to the lower lip to correct the
level of the corner of the mouth. This flap was not as big as is shown in diagram
190, and it should be noted that it runs across the scar line of the first flap, and is in reality
a partial replacement of the original flap. This manoeuvre was quite successful, as usual,
in restoring the level of the corner of the mouth. In regard to the eversion of the mucous
membrane of the upper lip, an arrow-head piece of skin was excised, as shown in the
diagram ; the edges when sewn up produced a satisfactory eversion of the mucous mem-
brane. To make this border more prominent, the subcutaneous fat and muscle from
the upper part of the lip was dissected from above downwards, and, whilst still partially
attached, was rolled down as a flap of tissue, which was then sutured into the free border,
the method of which was by mattress sutures, as indicated in the diagram, fig. 191. The
result of this procedure was quite definite in producing a prominence of the border of the
lip, and the aesthetic result was satisfactory. Functionally, it was quite good, except
that the mouth was not sufficiently large. But, as the patient was quite satisfied, he was
discharged.

1 See also Case 7, pagci 90, for method of avoiding this droop of the corner by excision of part of
the natural lip.

INJURIES OF THE UPPER LIP

113

FIG. 1 89. Excision of scar and ascending flap.

FIG. 188. Healed condition.

Fio. 1 90. Correction for depression of angle of mouth.

FIG. 191. Scheme to show arrow-head excision of skin,
and method of rolling down the soft tissues of the lip
to its edge, to produce prominence and presentation of
the vermilion border.
8

FIG. 192. Result.

114

PLASTIC SURGERY

CASE 295

Is that of an officer in the Field Artillei y. who was struck by a shell on September 27th,
1916. He was admitted nine months later for plastic treatment in the condition shown
in the first illustration. A large depressed scar ran horizontally across his check, ending
in various small scars in the remains of the right half of the upper lip. The underlying
loss of bone comprised the major portion of the right upper alveolar process and antciior
wall of the right antrum. The mucous membrane loss was practically nil, whereas the
skin of half the upper lip had been shot away, the vermilion border being drawn up by
the scar tissue, producing a marked ectropion. The right corner of the mouth was
normal, and the question of supplying the necessary amount of skin to cure this deformity
presented many difficulties. Had I used an ordinary imbedded ascending flap, the corner
of the mouth would undoubtedly have been seriously displaced, necessitating further
correcting operations. Descending flaps were contra-indicated on account of the scar
tissue and no hair being thereon. Two further designs presented themselves to me, both
of the ascending flap variety, the first of which necessitated excising the already existing
corner of the mouth, so as to imbed the flap, and it was therefore discarded ; the
remaining method, which was the one adopted, was to use an ascending flap, but to
imbed only the terminal portion of it, thus making it into a bridge flap, the pedicle
lying over healthy, untouched skin. The vermilion border was carefully preserved and
resutured, as is shown in the intermediate stage illustrations. The under raw surface
of the bridge was protected by waxed gauze, while two silk-worm sutures were passed
through the vermilion surface of both lips, at the right corner, in order to steady the
parts and to prevent oral secretions reaching the wounds. The return of the pedicle
was carried out on 7.9.17, i.e. on the eleventh day the bridge of the flap was cut in a
slanting direction just clear of where it had been sutured into the upper lip, and the
remaining free end of the graft was sutured into place. The pedicle of the bridge was
re-fitted into the check, and in doing this a small amount of granulation tissue had to be
cut away before the pedicle was replaced into its original position. It should be noted
that the under surface of the bridge was kept exceedingly clean, No. 7 Ambrine wax dressing
being used. The result, so far as the moustache and upper lip arc concerned, was all that
one could desire, and at the second stage of the operation a small portion of the redundant
mucous membrane was excised. As to the reinsertion of the pedicle, I doubt whether any
advantage has accrued. Owing to the slight granulations on its under surface, there was
a distinct tendency at first to present a somewhat rounded appearance ; but, although this
has subsided, there was no necessity to preserve this piece of skin in this particular case,
and the resulting scar-line might have been better than it is.

In regard to the depression of the check and the long scar, a dental apparatus
designed by Sir Francis Farmer has materially aided in bulging out the cheek ; but
this did not fill up the hollow in the cheek. A considerable free fat graft was successfully
implanted under the skin at a later stage, but the result of this is not illustrated.

Fio. 193. Illustrating " bridge " pedicle flap for upper lip and moustache.

INJURIES OF THE UPPER LIP

115

FIG. 194. The healed condition nine months after
wound. Ectropion from loss of skin surface.

FIG. 1 95. Bridge pedicle flap in position.

Flo. 190. Pedicle returned. Moustache grown,

Fio. 1 97. Ditto. Note : the hollow in the cheek
was filled by a free fat graft and excision of
scar at a later stage.

116

PLASTIC SURGERY

CASE 270

This case of a minor injury of the upper lip is included for one or two reasons. It
was due to the exit wound of a bullet which entered behind the right angle of the mandible,
which it broke, passed through into the month, and carried a few of the front teeth through
the upper lip. The blow in this case was very severe, and the officer told me that he felt
as if the whole of the face had been shattered. There is no important loss of tissue, but
the method of repair is interesting as an illustration of the value of overlapping flaps in
producing depth. The wound had caused the stellate explosion of the upper lip, and when
the case was sufficiently healed to conic for operation, six weeks after the battle of the
Somme, it presented a somewhat similar appearance to that shown in the illustration
which was taken in the semi-healed condition. The diagrams accompanying this record
indicate how each radiation of the scar was excised, and the little flaps thus outlined were
each prolonged by incision to a slight extent and then interlocked the one above the
other. Comparing this case with that of 143 and others in section on lower lips, the
value of this method of producing depth at the place one most wants it is, I think, estab-
lished. The second illustration is that of the condition just after the removal of the
stitches and the scar lines are plainly visible. When this officer returned to duty, he sent
me a photograph taken by an ordinary lay-photographer ; the growth of the moustache
has effected a perfect result.

Fio. 1 98. Exit wound of bullet. Semi-healed
condition.

INJURIES OF THE UPPER LIP

117

Fict. 1 99. Exoision and Incision

FIG. 200. Suture.

Fia. 201. On removal of stitches.

FIG. 202. Result. Photo taken by lay
photographer.

118 PLASTIC SURGERY

CASE 179

This is a very atypical deformity of the upper lip caused by a gunshot wound, received
on August 18th, 1916, details of which are lacking owing to the fact that the patient was
not admitted to me until March 1st, 1917, in the healed condition shown.

The scar near the angle of the mouth produced a very marked deformity of the upper
lip, and this case is not so much one of a restoration as it is one of a deformity. The interest
of the case, I think, revolves round the principle with which such condition should be treated.
The method actually used is very clearly shown in the diagrams. The large descending
flap, A, from the cheek, was swung down beyond the corner of the mouth, after excision
of all scar tissue. The natural flap, produced by excision of the scar, was stretched
upwards and backwards. The marked eversion of the vermilion border was very satis-
factorily cured, and the gain of tissue necessary to maintain this result was obtained at.
the expense of the tissue beneath the left eye, and the tension of this flap, which would
have a natural tendency to recede upwards, was taken from the flap, B, which, being
attached to the lower lip, prevented any late alteration in the replaced upper lip.

The photograph of the result was taken seven weeks after operation.

INJURIES OF THE UPPER LIP

119

FIG. 203. Nine months after wound.

Fio. 204. Excision and flaps. Flap B referred to
in text is that just below A.

Fio. 205. Suture. Flap .1 ' brought down to
a lower lip attachment at A. B (not marked)
swung backwards.

FIQ. 200. Result seven weeks after operation.

LOWER LIP AND BONE-GRAFTING OF

MANDIBLE

CHAPTER IV
INJURIES OF THE LOWER LIP AND CHIN

THIS chapter includes injuries to the lower lip, certain injuries involving both
lips and leading to conditions of contracted mouth, and injxvries to the soft
and hard tissues of the chin.

The injuries to the lower lip are arranged roughly in order of increasing
severity. There is a certain definite group which may be termed the Hare
Lip type, in which a satisfactory repair may be obtained by a simple advance-
ment of the remaining portions, the aesthetic and functional results varying
directly with the amount of tissue lost. When more than one-third of the
lower lip is missing, the result of the advancement repair ceases as a rule to
be satisfactory. It sometimes happens that the resulting diminished lower
lip fits in well with the loss of bony chin.

But in planning all repairs of the lower lip, .the first thought of the surgeon
must be to provide a satisfactory bed for a denture, with a buccal orifice of
such a size as will admit the necessary temporary or permanent appliance.

In the group of injuries leading to microstoma no account is taken of facial
burns, which, in the author's opinion, are by far the commonest cause of the
condition. Another important cause that should be here mentioned is inex-
perienced surgical procedure, such as omission to provide a lining membrane
for flaps.

Injuries to the chin naturally divide themselves into those of the soft tissues
only in which good functional and aesthetic repair is the rule and those
involving loss of bone. In those terrible cases in which the whole of the mandible
from molar region to molar region is carried away, the author has neither seen
nor performed any series of operations which may be said to have achieved
more than mediocre result as regards appearance and more than a very pool-
result as regards function. The condition is one analogous to loss of a limb,
and in the upshot a presentable appearance is often the mask of a skeleton of
surgical inefficacy.

The most serious difficulty in the way of functional repair is the provision
of a depressor musculature for the new jaw. One has several times seen what

123

PLASTIC SURGERY

appeared to be a moderately satisfactory repair, including a successful bone-
graft, prove wcllnigh worthless from lack of attachment of the suprahyoid
muscles and platysma. Little or no excursion of the mandible occurs, and
there remains a gross impairment of speech and of the first stage of deglutition.
It should be noted that the remaining fragment of the mandible assumes a
position determined by the removal of the muscles opposing the internal ptery-
goid, temporal, and external ptcrygoid muscles, as well as of the support afforded
by its continuity with the condyle of the opposite side. It is therefore swung
upwards, forwards and inwards, and somewhat protruded, and when the patient
tries to open his mouth, the deformity is merely accentuated.

In the attempt to provide a depressor musculature, in one case, in which
all idea of the formation of a bony chin had been abandoned in favour of an
intrabuccal dental appliance, the author dissected out and epithelialised what
remained of the anterior belly of the digastric.

The idea was to introduce it into the floor of the mouth, with a view to
attaching it to the denture by means of an artificial tendon after the manner
of Putti. But the exigencies of the service, and in the urgent necessity of
making the major repairs in this case, prevented the fulfilment of the plan.

There is, moreover, in these cases a total lack of control of the lower lip.
The author, in the attempt to relieve this, uses descending nasolabial flaps
which include some muscular fibres with nerve supply intact. These continue
to function in their new position, and, by tightening, effect some degree of
closure of the buccal orifice.

The simplest and, fortunately, the most common injury of the lower lip
is of the hare-lip variety, which requires for its repair excision of the scar, com-
bined with accurate resuture, and advancement or elevation of the tissues.

Where the lesion occurs near the corners of the lower lip it is the common
practice to advance the tissue situated laterally to the scar. The point of the
chin in these cases is usually in its normal position, and so the gain of tissue
that is required is obtained from the lateral aspect after excision of the scar.

A few cases illustrating this deformity are appended.

INJURIES OF THE LOWER LIP AND CHIN

125

Case 50 shows a lesion of the lower lip in the same region as in the previous cases,
with ectropion from scar tissue contraction. The diagram illustrates the method by
means of which the ascending flap was swung up to fill in the gap and to raise the lip.
No special point is to be noted in this case except that flap A was inserted between the lip
and the chin, and flap A being wedge-shaped, the more it was drawn in between them the
more the lip was raised.

FIG. 207. Healed condition. (Note ectropion of lip.)

FIG. 208. Excision of scar and freeing of flap.

FIG. 209. Suture.

FIG. 210. Result.

126 PLASTIC SURGERY

CASE 244

This case was wounded in Mesopotamia by a bullet which entered into the left super-
ciliary margin, and after perforating the bone there, re-entered it just below the left eye,
perforating also the left antrum and palate, and then carried through the lower jaw and
left side of the lower lip.

The external wounds were healed on admission to the Cambridge Hospital, Aldershot,
and the mandible, after sequestrotomy and extraction of involved teeth, united. The
palate was also replaced by a dental appliance, under the supervision of Captain L. A. B.
King, R.A.M.C.

The lower lip was treated in the following manner : The loss of tissue being trifling,
the scar was freely excised and adhesion to the mandible freed. Three natural flaps were
thus outlined, and the two lateral ones advanced in the V Y fashion. The mucous membrane
was treated separately and specially, so as not to get depression at the point of union. The
vermilion border attached to the left corner of the mouth was dissected back to the corner
along the muco-cutaneous junction ; that on the main portion of the lip was similarly divided
along the muco-cutaneous border until it could be easily advanced to the left corner of the
lip, where it was resutured. Its upper border was then freshened, and the little flap attached
to the left corner sutured into this freshened area. The advantage of this method of dealing
with the mucous-membrane suture is that the union of the two halves of the vermilion
border is on a different vertical plane from that of the skin, and there is no tendency to
a dimple at the junction.

Two of the photographs illustrating this case are of pastel drawings by Professor Henry
Tonks, the ordinary negatives not being available.

INJURIES OF THE LOWER LIP AND CHIN

127

Fio. 211. Healed condition.

Fio. 212. After operation.

Mucous flap
turned back
Raw surface shaded
to meet similar
raised surface on A-

FIG. 213.

1-28 PLASTIC SURGERY

CASE 58

was a Royal Flying Corps officer, who was wounded by seven machine-gun bullets, at Kut,
in Mesopotamia. The wound that is here illustrated was caused by one of the bullets.

There was a loss of mandible of about one and a half inches in the right prc-molar region.
The dense scar in this region extended up to the vermilion border of the lip, which was
dragged down with it. The scar was of a radiating character, and, on excision, it was found
that the free portion of the lip came back into position easily, but in order to fill up the
large gap, caused by the excision of the scar, with healthy tissue, it was necessary to make
a swinging advancement of the cheek in the neighbourhood. This is illustrated in the
diagram, and is visible in the photograph showing the result. This flap also prevented a
tendency to eversion of the lip on the one hand, and, on the other, to the displacement of
the soft tissues of the chin to the right, which would have occurred had a straight " sew-up "
been attempted.

This officer was submitted to a bone-graft operation seven months after being wounded,
and four months after the plastic. The bone-graft was eminently successful, and notes of
this operation and of X-rays follow :

17.3.17. Operation (Captain Gillies). Ends of bone cut down upon and isolated from
adherent tissues, and inferior dental canal in both fragments reamed out. A gap of one inch
separated the fragments. A rib-graft was taken from right thorax with periosteum attached
on outer surface, with an overlap of about half an inch at each end. The extremities of
graft were pointed and these points engaged in reamed-out canal of fractured ends of man-
dible. Wound sutured with horsehair. Drainage (gut). Wound healed by primary
intention.

23.4.17. X-ray shows bone-graft in excellent position. Much callus being thrown
out around its posterior anchorage.

February 1919. Examined by the judging committee of the Odontological Section
of the Royal Society of Medicine, and pronounced to have firm bony union and 90 per cent,
function.

This and the preceding cases had no serious shortage of the mucous membrane.

INJURIES OF THE LOWER LIP AND CHIN

129

FIG. 214. Healed condition.

Fm. 215. Excision of scar and advancement
of cheek flap.

Fio. 216 Suture.

FIG. 217. Result.

PLASTIC SURGERY

The next cases are examples of injuries to the corners of the mouth, and
do not exactly belong to either the Upper or Lower Lip group.

CASE 5

In Case 5 a large piece of shell entered at one angle of the mouth and eame out through
the opposite side, fracturing the mandible and tearing away the adjacent portions of the
cheek. This patient was wounded on July 1st, 1916, and fig. 218 shows the rendition on
admission two days after being hit. Unfortunately, a graphic record of his healed condition
was not taken. The X-rays showed fracture of the mandible in two places in the region
of the first molar tooth, and in the region of the symphysis, the intermediate portion of
bone being displaced.

Plastic operation was undertaken on September llth, 1916, and consisted in excision
of scars on both sides.

On the right side the two surfaces of the cheek were merely drawn together, and the
mucous membrane from the inside of the mouth brought out to form a new angle (fig. 219).

On the left side, a combined skin and mucous membrane flap was swung towards the
oral opening both in the upper and lower lips (vide figs. 219 and 220).

FIG. 218. Early condition.

Fio. 219. First plastic. Excision and suture.

The result of this operation was satisfactory, except that the movement of the lower
jaw began to stretch the line of union of the flaps on the right side of the cheek, and the
wound partially broke down near the corners of the mouth (fig. 221). It was limited by
immediately fitting a closely applied chin-splint and attaching it over the head. Since
then, in all eases in this region, I have been careful to support the lower jaw until the opera-
tion wound is well healed.

Second plastic operation (October 31st, 1916). Scar re-excised, and, in order to raise
the corner of the mouth a little, a flap was outlined as per diagram (fig. 223) and sutured to
the lower lip.

Third plastic operation (January 1st, 1917). A portion of the right scar having again
broken down, it was re-excised, the knife being used obliquely to the skin surface. Local
iat-flaps were turned in from above and below the depression, sutured together with catgut,

INJURIES OF THE LOWER LIP AND CHIN

131

and the skin sewn over this pad with fine interrupted horsehair. A small mucous membrane
correction was made on the left upper lip, and the left lower lip was raised at the corner by
sewing up perpendicularly a horizontal incision through the whole thickness of the lip
(fig, 224).

FIG. 221. After first plastic.

FIG. 222. Final.

FIG. 223. Second plastic.

FIG. 224. Method used to raise lower lip.

Figs. 218, 222 and 221 show the condition before and ; after treatment, and the stage
after the first operation.

Firm bony union of the lower jaw has occurred, and the patient can eat solid food.
Further improvement could be effected by bringing down the upper lip at the left angle.

The dental work was carried out by Captain F. E. Sprawson, R.A.M.C.

The diagrams illustrating the operations were drawn by Professor Henry Tonks.

I.T2 PLASTIC SURGERY

CASE 563

Probably at the time of injury this was a similar type to that of Case 5, but a less
serious wound.

The mouth had healed well, but with a marked microstoma, which was a functional
disability. There were also disfiguring scars at the corners of the mouth.

Previous history was not obtainable, and the only interest in the case is that of the
widening of the buccal orifice. A thin, triangular portion of skin and scar tissue was
excised at each angle of the mouth. The mucous membrane was well divided in the middle,
and then sutured to the skin.

The improvement in the microstoma was very marked, and the appearance was quite
satisfactory, although the photograph of the final condition was taken without the presence
of dentures.

I include this case because I think a slightly better appearance is obtained when a
small portion of the skin and subcutaneous tissue is excised to allow the mucous membrane
to curl round and show itself.

INJURIES OF THE LOWER LIP AND CHIN

133

FIG. 225. Healed condition.

Fio. 226. Microstoma relieved.

PLASTIC SURGERY

Three cases of loss of the central portion of the lower lip are next discussed.

In two of these the condition seen after wounding is represented photo-
graphically, and in one of them (Case 62) the healed stage is available.

I'nfamiliarity with this class of injury leads one to think that the material
loss is very much greater than it actually is.

CASE 62

Corporal C , was admitted on 6.7.16, five days after being wounded, with fracture of

the jaw in the symphysis region and loss of the middle third of the lip.

When the bone condition had been successfully controlled and the sequestra had all
come away, a plastic operation was performed for me by Lieutenant Dixon, R.A.M.C.,
with the assistance of Lieutenant C. B. Tudehope, R.A.M.C., and after excision of the scar,
which went down to the bone, the flap on the right was swung upwards and to the left,
while that on the left was undercut and raised.

The new lower lip was considerably shorter than his original one, but is sufficiently
satisfactory from both cosmetic and functional points of view.

Flo. 227. On admission.

FiG.228. Healed condition.

INJURIES OF THE LOWER LIP AND CHIN

135

FIG. 229. Excision of Scar : flaps outlined.

Fio. 230. After first plastic.

FIG. 231. Final after excision of scar.

130

PLASTIC SURGERY

CASE 256

Another type treated by excision of scar,
and raising of the halves of the lip, is also
illustrated.

Note the apparent seventy of the lip
injury, which is obviously a photographic
effect.

The operation notes are :

Private Mc.H , admitted 19.8.16.

Condition. Slight loss of tissue of lower
lip with the two halves firmly united to man-
dible and presenting a V-shaped gap.

29.9.16. Operation (Lieutenant Tude-
hopc). Type freeing of lip-halves and pro-
longation of the incision lateralwards to allow
necessary depth on resuture.

Result. Satisfactory. Slight scarring.
Discharged, duty, 7.2.17.

FIG. 222. Early condition.

Fio. 233. Healed condition.

Fid. 234. After lip plastic.

INJURIES OF THE LOWER LIP AND CHIN

137

CASE 205

This is another simple type giving satisfactory result.

It was necessary, however, very carefully to adjust the mucous membrane on the inner
side of the flap.

The jaw was in process of uniting, and an artificial set of teeth was fitted over the
splint (Captain L. A. B. King, R.A.M.C.), to enable the plastic to be more accurately per-
formed.

FIG. 235. Healed condition.

FIG. 236. After plastic.

138

PLASTIC SURGERY

The following two cases show clearly the loss of the lip and its red margin,
reparable by a forward-swung mucous membrane flap. In each case the skin and
subcutaneous tissue loss was made good by a descending flap, or flap of election,
taken from the nasolabial fold.

CASE 198

showed a elean loss of the central third of the free portion of the lower lip. The scar having
been excised, the mucous membrane was advanced across the gap, and a flap of suitable
size, was brought down from the left of the nasolabial fold, and sutured into position. The
terminal portion of this flap, for an obscure reason, went blue, and was lost through dry
gangrene. Perhaps the pedicle of this flap was a little too small.

The result after the operation wound had healed as shown in the second photograph,
and presents an ugly scar and notch in the middle line. Later, this was excised, and by a
VY double swinging advancement a deep and satisfactory lip was obtained.

FlO. 237. On admission.

INJURIES OF THE LOWER LIP AND CHIN

139

'&:. Mucous flap from
inside of cheek.

FIG. 238. Steps in first plastic.

Fia. 239. After Orst plastic.

FIG. 240. Final plastic.

140

PLASTIC SURGERY

CASE 8

Tlie mucous membrane shown in Professor Tonks's pastel (photo represented) was
carefully preserved by stitching it to the skin margin in the early stages of this man's wound.

\Ylten the large wound on the right side of the check had healed, a plastic operation
was undertaken for me by Lieutenant C. B. Tudehope, R.A.M.C. The corner of the mouth
had been dragged down by the sear, and was relieved by its excision. In order to improve
the position of the corner of the mouth and maintain it at a correct level, a descending
flap from the right nasolabial fold, containing skin and subcutaneous tissue, was swung
down and sutured beneath the readjusted vermilion border. A pleasing effect was thereby
produced, but it might have been possible to raise the centre of the lip a shade more by
making the flap a little longer.

Fio. 241. Early condition.

FIG. 242. After plastic.

INJURIES OF THE LOWER LIP AND CHIN

141

CASE 243

This needs little explanation. Not only were the two lateral flaps, A and A', advanced
and swung upwards in the V Y fashion, but the apex of the V was itself raised by suture to
the deep tissues. The result is suffieiently satisfactory. The bone lesion was one of con-
siderable comminution, and the case healed with a pseudarthrosis in the mandible. This
was treated by excision, and inlay of an osteo-periosteal graft from the tibia, with the
result that bony union occurred. Five months after the bone operation the patient was
discharged to duty.

FIG. 243. Healed condition.

FIG. 244. Excision of scar and delimitation of flaps.

Via. 245. Suture.

Fia. 240. Result.

1 I'-'

PLASTIC SURGERY

CASE 45

Graphic records of the condition on the tenth day after wound and after the parts
became soundly healed are given.

The loss of tissue comprised the left half of the lip in all its layers, the shortage of
mucous membrane being considerable.

The method of plastic repair consisted of a descending nasolabial flap for the skin and
muscular layers, combined with an advancement flap of the mucous membrane.

The result was fairly satisfactory from the cosmetic point of view, but there is no doubt
that the mucous membrane was still very short, and, owing to adhesion between the new
lower lip and cheek and the mandible on the left side, the fitting of an artificial denture
became a serious difficulty. This was subsequently remedied by an epithelial inlay by
KSMT'S method, with moderately good functional result.

I think the mucous membrane difficulty in this case might have been better met in
the first instance by taking a whole-thickness flap from the nasolabial region. An alternative
which would have acted well would have been to make a new sulcus along the mandible
before undertaking the plastic closure. Another way of dealing with this, but requiring
more extensive flaps, would have been to turn in the skin in the neighbourhood of the
scar to form the buccal lining.

It will be noted that the nasolabial flap was carried to a point, the reason for which
has already been discussed.

Fio. 247. Early condition.

INJURIES OF THE LOWER LIP AND CHIN

143

->^te^-

FIG. 248. Healed condition.

Fio. 249. Excision of scar and delineation of
descending nasolabial flap.

FIG. 250. Suture.

FIG. 251. Present stage.

144 PLASTIC SURGERY

CASE 2

'1 his case is one of interest and also of partial failure. The interest lies in the ring-like
injury of the month.

The mucous membrane healed with great tendency to keloidal scar tissue, and. despite
the persistent use of apparatus, made under the supervision of Captain L. A. B. King,
R.A.M.C., attempts to prevent the mouth contracting failed, and a marked condition of
mierostorna was present when the lips were healed. The buccal orifice was surrounded by
an unyielding ring of scar tissue, giving a maximum width of 1J inches. The loss of tissue
\\;IN mainly in the lower lip, the mucous membrane of which was entirely absent.
Before plastic repair, a preliminary excision of all scar tissue was performed.
In regard to the upper lip, careful resuture, combined with the pulling out of the
mucous membrane, gave a sufficiently satisfactory result.

For the lower lip, double nasolabial descending flaps were used, that on the left being
longer than that on the right. These were taken down to the muscular layer only, part
of which was included in the flap. Such mucous membrane as was provided for this lip
was taken from a similar area to the skin-flaps, but as independent flaps. The result was
moderate so far as appearance is concerned, and the fault was due to the fact that there
was a great shortage of the lining membrane of the lip and of the lower sulcus, which pre-
vented the fitting of. a satisfactory lower denture.

This patient refused further treatment at the time, but there is no doubt that a most
satisfactory functional and cosmetic effect would be produced by a successful epithelial
inlay between the gum and new lower lip. The scar tissue of the lower lip had been very
successfully got rid of, and the new one was of great softness and pliability, with a certain
amount of muscular movement, which made one regret the inability to complete the case.

Flo. 252. Early condition.

INJURIES OF THE LOWER LIP AND CHIN

145

Fia. 253. Healed condition.

FIG. 25-t. Excision of scar and outlining of flaps.

Fio. 255. Suture.

FIG. 250. Final.
(I'atient refused further treatment.)

146

PLASTIC SURGERY

lost.

The diagnosis in these injuries rests on the accurate estimation of the tissues

CASE 99

The photograph taken on admission seven days after the receiving of the wound shows
that the loss of tissue comprised the right two-thirds of the free border of the lower lip,
together with an injury of the cheek. The destruction of the mucous membrane does not
go down to the lower buccal sulcus ; consequently, the shortage of mucous membrane is
not so great as it might appear from examination of the photographic record. The photo
of the healed condition is not available.

The result of the first operation was moderately good. The operation notes show that
when the scar tissue was removed the loss of tissue was roughly represented by what I have
already described and what was apparent before the healing had commenced.

Two swinging advancement flaps were utilised to make good the main body of the lip,
while mucous flaps were able to be cut and brought out to remake the vermilion border.
Subsequent minor corrections were carried out to overcome this shortage, the main one
of which consisted of a flap of mucous membrane, taken from the upper lip and sewn to
the lower.

Note. On discharge from hospital the mouth was slightly contracted.

Fio. 257. Early condition.

Fio. 258. Excision of scar and outlining of flaps.

INJURIES OF THE LOWER LIP AND CHIN

147

Via. 259. Suture.

Fio. 260. Early result.

FIG. 261. After minor corrections.

148

PLASTIC SURGERY

CASE 137

Private W - is the only example in this series of cases in which a combined skin,
muscle, and mucous membrane flap was taken from the nasolabial fold and brought down
to make the lip. The loss of tissue in the early and healed conditions is shown in ligs.
2(52 and 263. The shortage of mucous membrane was rather greater than is apparent.

This whole-thickness flap, cut with square ends, was found to be too thick when brought
down, and the middle fatty layer was dissected out from the outer and inner edges in order
to reduce its thickness. (See Professor Tonks's diagrams.) Even then, the lip was a little
too fat, and bad suture lines spoiled what would otherwise have been a very perfect result.
The lip had excellent function, and was very pliable.

Diagrams are below, and the record of the condition of this man on admission is a re-
production of one of Professor Tonks's exceptional drawings in pastel.

FIG. 2fi2. Early condition.

INJURIES OF THE LOWER LIP AND CHIN

149

Fia. 263. Healed condition.

Fio. 204. Excision of scar and outlining of (lap.

FIG. 265. Excision of fatty layer from flap.

FIG. 260. Suture.

Fio. 207. Final.

PLASTIC SURGERY

CASE 184

This case is one full of interest in all its stages. This gallant trooper was wounded and
eaptured while on distant outpost duty in the wilds of East Africa. In addition to a
fractured arm and loss of the lower lip, severe dysentery followed owing to insufficient
medical care. He made good his escape, and, after tramping through the Bush country
a journey of about 150 miles he managed to get under British medical treatment.

lie had been operated on twice by his captors for his jaw condition, and on eventually
arriving in my clinic all wounds were healed and his condition was as shown in fig. 268. The
loss comprised the greater part of the free portion of the lower lip in all its layers. A
stump of the lip remained, however, at each corner.

The first operation was moderately success-
ful, and its method of gaining tissue to remake
the lower lip consisted of a partially descending
swinging advancement from the left cheek, and
this flap was drawn and sutured above the
existing chin skin, and the mucous membrane
from either side advanced over its upper border.
The diagram roughly represents its principle.

Five months later, the new lip was in a con-
dition of entropion, as would be expected, the
mucous membrane being too short to allow the lip
to be sufficiently free. In addition, there was no
inferior sulcus on which an efficient denture could
be carried, a condition which was accentuated by
the fact that the alveolar bone had been de-
stroyed. It was decided to employ the Esser
inlay for this entropic condition, with most
satisfactory results, the date of this operation
being 21.9.17.

This was the first of its kind that the author
had done, or seen done, and it was probably the
first case treated by this method in this country.
FIG. 208. Healed condition. A discussion on the matter with Major Waldron

Fid. 269. Descending nasolabial flap.

FIG. 270. Suture.

INJURIES OF THE LOWER LIP AND CHIN

151

FIG. 271. Condition after descending nasolabial
flap operation.

C.A.M.C., who advised the perusal of Esser's
article, led to the adoption of this means of
treating the condition.

An exceptionally efficient denture was
now applicable, and in the fitting of this the
patient had the advantage of Sir Francis
Farmer's skill.

Following the freeing of this lip by the
Esser inlay, the lip was raised by a nasola-
bial fold, taken from the left side. A marked
bossing of this flap occurred, which diminished
very slowly, and the reason for this lymphatic
stasis is, as yet, I think, an undiscovered
factor.

One has not discovered the reason why
some of these flaps show this rounding and
others not. In this particular case, it is pos-
sible that the skin-graft on the inner aspect
of the lip had something to do with the ab-
sence of drainage from the area.
In addition to this being due to lymphatic blockage, there is undoubtedly a certain
amount of fibrosis which occurs in the bed of the flap. For this reason, it was decided to
operate again, and at the same time to get. an everted free margin of the lower lip. Incision
was made along the line A B in fig. 272, which lay along the existing muco-cutaneous
junction. This incision also was carried down along the suture-line to the right, the scar
of the suture-line being excised. The skin was then carefully undermined, leaving the
subcutaneous tissue in position, and this undermining was continued below the lower scar
of the rounded flap. Then a large amount of the subcutaneous tissue was dissected from
below upwards, and made to lie between the mucous membrane and skin of the original
incision, as shown in the diagram, D in fig. 273. This allowed the skin of the rounded flap to
go flat. Next, the now exposed fat-flap D lying between the skin and the mucous membrane
was covered by mucous membrane flap C from the
upper lip.

The method of making a vermilion border from one
lip to the other is typified in this case. I give particulars
of the technique used. The upper lip was well raised
forward, and the mouth well packed to prevent blood
going down, and incision was made along the gingivolabial
junction of the central portion of the upper lip. Two
perpendicular cuts to the free margin were carried from
extremities of this incision. This mucous flap, thus out-
lined, was reflected from above downwards until it well
covered the fat flap D without tension. The sutures
necessary to retain this mucous membrane flap were
now inserted without being tied ; they consisted of one
relaxation suture of silk-worm gut from the upper lip to

the chin, next a row of four horsehair sutures was

' _ , FIG. 272. Incision along muco

inserted through the mucous nap, and lour mat.ress cutaneous junction (D the 'dotted

area, represents a subcutaneous flap
which was elevated to form a basis
for new vermilion border.)

horsehair sutures through the mucous flap joining it to
the mucous membrane of the lower lip. These were in-
serted about \ in. from the free border of the mucous
flap, so that sufficient mucous membrane remained to go over D to join the skin.
These sutures being got into position, the mouth plugging was removed, and relaxation
and backrow sutures were tied. It remained to join the free edge of the mucous flap to the
skin of the lower lip. An anaesthetic was given for this operation by Captain J. C.

1 .->_>

PLASTIC SURGERY

Clayton, R.A.M.C., ether, nasal tubes, and mouth-packing being used a particularly
satisfactory procedure in this case.

Diagrams of this procedure and a photograph of the lip in this stage showing the back
row of sutures in position accompany these notes.

FIG. 273. Subcutaneous fat flap (D)
being raised from chin region to help form
lip.

FIG. 274. Mucous flap from upper
lip outlined.

Fia. 27C. Front view of Fig. 275.

Fia. 275. Mucous flap swung from
upper to lower lip.

Fia. 277. Mucous flap being sutured into place.
(Note retention suture.)

INJURIES OF THE LOWER LIP AND CHIN

153

The broad pedicle of this mucous flap was detached under novocaine ten days later.
Feeding was maintained by passing a tube through the corner of the mouth.

Owing to the excellent result, one was encouraged to fill up the corners by mucous-
membrane flaps from the lateral portions of the upper lip,

Anaesthesia for this operation was obtained by blocking the infra-orbital nerve at its
exit from the canal, and by local novocaine infiltration to the lower lip.

FIG. 278. Mucous flap from upper lip applied to
lower lip. (Patient fed through a tube in corner
of mouth.)

FIG. 279. Final, showing new vermilion border
for lower lip.

PLASTIC SURGERY

CASE 188

A very good result was obtained in this case. The healed and early conditions
show a loss of more than half of the lower lip through all its thickness, but the tissues
of the chin are merely displaced in the freshly wounded condition.

Only one operation was done on this lip, and by good fortune a more than satisfactory
result was obtained by it. The main principle of it was a descending nasolabial fold- flap,
which was deepened to the muscular layer only and brought down to meet the right portion
of the lip remaining, which was, at the same time, advanced and raised. The lining was
obtained by freeing a stump of mucous membrane present at the left corner of the mouth,
and converting it by undercutting into a flap which was advanced across the new lip to
meet the existing vermilion border of the right.

A large gap in the bone, some 2| in., now existed, and a bone-graft operation was
performed ten months after the wound. The rib-graft was wedged between the fragments,
and a bone-peg was used to fix the posterior end of the graft to the angle of the ascending
ramus. The patient was edentulous, and the difficulty of the fixation of the fragments
was not sufficiently overcome to obtain fixation of the graft. It was noticed on the fourth
day that a drop or two of fluid came away from the mouth, which was due to the bone-peg
working loose and perforating the mucous membrane. Inevitable suppuration followed,
and the graft was eventually removed. Its place was, however, taken by a strong ostco-
fibrous band, which was of some functional use to the patient, whose age was thirty-five.

INJURIES OF THE LOWER LIP AND CHIN

155

FIG. 280. Early condition.

FIG. 281. Henled condition.

FiQ. 282. After plastic and bone graft.

I.-,.; PLASTIC SURGERY

CASE 236

This was a combined case of Captain Aymard's and the author's. This South African
soldier was severely wounded in the lower lip and mandible, in the battle of the Somnie. The
healed condition is not shown. The loss of tissue consisted of the central two-thirds of the
free margin. The natural flap, which is shown lying semi-detached in the first photograph,
was utilised by me in the first operation. This natural flap was enlarged by incisions in the
downward direction, and maintained by deep catgut sutures to the periosteum of the surface
of the symphysis. A mucous flap was drawn from the left side to cover a portion of the lip.

Captain Aymard, K.A.M.C., then undertook the completion of the case, and by ad-
vancement of flaps, shown in the diagram, achieved a deepening and widening of the lower
lip, while the mucous membrane was provided from the upper lip.

The appearance of tin's new vermilion border was distinctly pleasing.

.--

FlO. 283. Early condition.

INJURIES OF THE LOWER LIP AND CHIN

157

x''"-

Fio. 284. After first "plastic.

Fia. 285. Mucous flap from upper for lower lip
and skin flaps outlined.

I I

Fio. 2SG. Flaps swung and sutured.

Fio. 287. Final.

158 PLASTIC SURGERY

CASE 535

This soldier received a shell-wound of the mandible and chin. The destruction involved
the mandible to the extent of some two and a half inches between the left canine and the
right molar region ; it involved the soft tissues over a similar area, but the mucous membrane
of the left third of the lower lip remained, and the healing process extended downwards
along the raw edge.

The fragments of the mandible were maintained in a good position in the early stages
by dental splints.

The case cleaned up rapidly, as such cases of large losses usually do.

The method of repair designed was by double epithelial flaps, and as a preliminary
the defined area outlined for the flap, which was going to be turned skin surface inwards,
was subjected to X-rays for epilation. The effect of this was not entirely satisfactory as
regards the killing of the hair follicles, even though it was pushed to the extent of causing
a small burn.

The first operation was performed on the line designed, and the skin below and lateral
to the gap was raised in two flaps and turned skin surface inwards, and there sutured to the
existing mucous membrane. Along the top of this new skin-lining the remaining mucous
membrane was stretched and found to be adequate to complete the vermilion border. The
raw area caused by this transposition of skin was accurately measured with a template and
a flap of skin from the right aspect of the neck and chest swung upwards to fill the gap.
The area from which this flap was taken was partly closed by approximation and partly
left open to heal by granulation.

The result was satisfactory.

This operation was performed over a prosthesis representing the missing portion of
the mandible, supported laterally on the two fragments. It was found, however, that in
the after-treatment the pressure of the flaps on the apparatus was too great, and the latter
was removed to avoid gangrene. It was found later that the new chin and lip were so soft
that they could easily be pushed out into any position. The result of this stage is shown
in fig. 292.

In addition to the lack of depth of the new lip, there was marked absence of movement
in this newly made portion. To improve both of these defects, it was decided to swing
down a nasolabial flap on the right side and to interpose it between the upper border of the
neck-flap and the vermilion border. The vermilion border and the inturned skin-flaps were
freely undercut, so that they could be lengthened to cover over satisfactorily the inner
surface of the nasolabial flap.

The result was gratifying, both as regards appearance and movement of the lip, the
latter being quite remarkable.

It remains to insert a bone-graft of the necessary length, which should present no
difficulty.

The method adopted in this case is better than that in the one which follows.

The fragments of the mandible were maintained in better position, in the first place
by splints, and in the second by the turning-in of an adequate epithelial lining, while in
the next case the mandibular arch was contracted mainly due to advancing the existing
mucous membrane across the gap.

INJURIES OF THE LOWER LIP AND CHIN

159

Fio. 288. Early condition.

Fio. 289. Healed condition (full face).

I , YlJX r ^x

i *&~~^ / v ^

FIG. 290. Healed condition (profile).

FIG. 291. Showing inturned flaps for lining and
ascending neck flap for covering of new lower lip.

100

PLASTIC SFRGKRY

FlO. 292.-- After first plastic : no muscular
control of lip.

FIG. 293. Nasolabial cutaneo-muscular flap
brought down.

FIG. 291. Present condition.

INJURIES OF THE LOWER LIP AND CHIN

161

CASE 160

This case did not require any special flap to complete repair after excision of the scar.
There was a considerable soft-tissue gap to fill, and the point of the chin was pulled to the
right by the suture.

The early condition of this patient was not recorded by photograph, but in the wound
on the right side the body of the mandible was exposed for fully one inch and a half, as a
wide devitalised piece of bone. It was, however, firmly attached to the posterior fragment,
and, as a means of maintaining the position of this fragment, I retained it and passed a silver
wire from the extremity of this dead end to the anterior fragment.

In the course of time this fragment was exfoliated and the wire taken out.

At the plastic, performed on 19.3.17, a gap in the bone still persisted, which was treated
by an osteo-periosteal inlay, by the following method :

The loss of bone was more of the lower than of the alveolar border, and after freshening
the ends it was found possible to put a retaining wire through the alveolar portions. In
elevating the mucous membrane from the bone, however, a perforation in the buccal cavity
occurred, which was closed as far as possible by catgut sutures. Across the main portion
of the gap an osteo-periosteal graft was laid in two portions : one on the internal and another
on the external aspect.

Some mild suppuration occurred after this operation, with a few drops of pus per day,
which persisted until a few small splinters of the grafted bone came away and the wire
was removed. Bony union was obtained by allowing the posterior fragment to swing
forward a little, and the graft probably only acted as a means of carrying bone-forming
cells from one fragment to the other. There was still a depression of the scar after bony
union had been obtained, and the cicatrix was removed and a free fat graft, from the ab-
dominal wall, inserted, to reproduce the contour. This was done on 7.9.17, and the
effect is well seen in the photograph, which was taken two months after the operation.

The scar in the neck is one made for ligature of the external carotid artery.

FIG. 295. Healed condition.

FIG. 296. Intermediate stage.

FIG. 297. Final.

PLASTIC SURGERY

CASE 79

This is a type of case which is intermediate between the preceding group and the two
cases that are next described, and is characterised by a very large loss of chin and lower
lip, together with the underlying bone. But the way in which this case differs from the
more extensive loss is that a considerable amount of the vermilion border has been preserved
as well as the lateral portion of the chin.

Fig. 299 shows the case after it healed, and with an appliance over which the plastic
operation was performed. The principle of this operation was that the existing vermilion
border was utilised to form the new lip margin ; and mucous flaps were drawn from inside
the mouth across the back of the new lip.

To make good the loss of the chin, a large descending flap, from the left nasolabial area,
was swung down and sutured to the surrounding parts, over the prosthesis. The end of
this flap was lost through want of blood-supply, and the reason of its loss was twofold.
In the first place, there was rather a sharp edge to the appliance, and in suturing this long
flap a double retention suture, with buttons, from the flap to the sound tissues on the right
was utilised. This suture pressed the flap too firmly to the edge of the prosthesis, and by
the time the blueness of the flap was observed, it was too late to save it. The other reason
probably was that it had no skin lining on its oral surface. The result after this accident
had occurred and the parts had all healed up, is shown in the next diagram, and a second
plastic operation was done two and a half months later.

The flaps are indicated in the diagram, and the final plastic result is shown, photographs
taken a year later.

During this interval a long rib-graft had been attempted from one fragment to the
other. The operation wound of the bone-graft healed by first intention, and no discharge
occurred subsequently. However, owing to probably insufficient apposition between the
bone-graft and the mandible, bony union did not occur, and some absorption of the graft
took place.

A moderately satisfactory dental appliance, in the form of a denture, was however
fitted, and semi-solid diet could be managed with the aid of this appliance.

Notes of case are given below :

Private C. L , wounded, France, June 30th, 1916, admitted 2.7.16. G.S.W. 2,

1 severe, 4 lower jaw.

2.12.16. Operation (Captain Gillies). For the formation of the lower lip and chin.
Owing to lateral scarring, the only flap from the face available was one taken from

the left side of the nose and extending in a curve towards the lower part of the left ear where
its base was situated. The mucous membrane and skin which had become attached to the
jaw on the right side were cut through their whole thickness and swung forward to form
the right portion of the lip ; a relaxation suture was inserted between the two, as very
considerable tension was observed on the left skin-flap. The whole operation was done
over an artificial denture and chin. Result : a considerable portion of the end of the left
flap sloughed, and a triangular space on the left cheek was left uncovered, as well as the
lower portion of the wound.

Operation. February 28th, 1917, to close circular opening below lower lip, left from
sloughing of flap after last operation. The opening was surrounded with scar tissue, which
was removed (as in fig. 303).

13.6.17. Operation (Captain Gillies). Incision below mandible. Exposure of ends
of fracture.

Graft was taken from the right seventh rib. A hole was drilled in the right fragment and
a peg of bone on left fragment was shaped to carry the graft. The splint was very stiff,
and it was found very difficult to immobilise the fragments. This mobility resulted, un-
fortunately, in breaking off the peg on the posterior fragment, and the graft was not therefore
fixed into the bone on the left side.

6.1.18. Upper denture fixed. There is some movement between two fragments of
jaw. X-ray shows the graft apparently united at one end.

INJURIES OF THE LOWER LIP AND CHIN

163

Fio. 298. Early condition.

FIG. 299. Healed condition.

FIG. 300. First plastic : Outlining of flaps.

FIG. 301. First plastic : Suture.

164

PLASTIC SURGERY

Fid. 302. Result of first plastic.

FIG. 303. Second plastic : Excision of scar.

FlO. 304. Second plastic : Suture.

Fid. 305. After final plastic.

INJURIES OF THE LOWER LIP AND CHIN

165

Injuries of the soft tissues of the chin below the lower lip do not visually
require more than excision of the scar tissue, in the usual manner.
The following two cases, however, have special interest :

CASE 32

This case has a photographic record of his early condition, but not one when it was
healed. The mandible united after the comminuted fracture present about ten weeks after
the injury and the external wound healed with a large depressed scar, adherent to the
bone. He was wounded on 1.7.16, and the first plastic operation was performed three
months later. After excision of the scar, a celluloid plate was inserted to raise the scar and
to give the necessary contour, the plate being held in position by catgut sutures to the
periosteum of the mandible. This operation was followed by continued small haemorrhages,
and the celluloid plate was removed. Two months later the scar was re-excised, and a
free fat-graft from the buttock was inserted. The result of this fat-graft was very successful,
and gave an excellent contour. Whether any absorption has since occurred is not deter-
minable, as the patient was discharged to duty a month after the graft.

Fio. 306. Early condition.

FIG. 307. -Final : Contour restored by free fat-graft.

1GG

PLASTIC SURGERY

CASE 129

Tliis case had large central loss of the soft tissues of the chin, which healed vip, with
a puckered, depressed scar. There was some ectropion of the lower lip, due to the pull of
the scar.

The healed condition, prior to operation, is shown in fig. 309. It will be noted that
there are considerable radiations of the scar extending upwards and downwards from the
main body of the scar.

However, excision was practised, and the resultant gap which presented itself for
repair closely resembled that seen in fig. 308, which is that of the early effect of the wound.

A difficulty thus presented itself somewhat unexpectedly, as the direct approximation
of the two skin-edges was found to evert the lip considerably. A decision had to be made
between the interposition of a flap between the two skin-edges or undercutting very freely
a lower flap and suturing it to the chin with deep catgut. The latter procedure was the one
adopted, but although this was markedly improved there was some eversion of the lip
remaining, in addition to a smaller scar than hitherto.

In reviewing this case, there is no doubt that it would have been better to have employed
a flap. There is always considerable difficulty in undercutting the tissues of the chin, and
the greatest benefit is to be obtained in this region by carefully sewing up the lower flap by
catgut to the periosteum overlying the mandible.

The reason for showing this case, which is an indifferent result, is to bring forward the
difficulties one experiences in this particular region.

Flo. 308. Early condition.

FIG. 309. Healed condition. (Stain due to
iodine.)

INJURIES OF THE LOWER LIP AND CHIN

167

FIG. 310. Excision of scar.

FIG. 311. Suture.

FIG. 312. Indifferent result (see text).

168

PLASTIC SURGERY

CASE 139

This is published, although an unfinished case. It is shown as an attempt at restoration
in that not uncommon class of gunshot wound of the jaw in which the whole body of the
mandible and the soft overlying tissues have been blown away en masse. The photograph
of this patient, taken soon after admission, sufficiently explains the extent of the lesion.
It is an interesting point to note that this gallant fellow walked several miles to the dressing
station on July 4th, 1916, during the battle of the Somme, and this very feat of endurance,
maintaining, as it did, the upright position, may have prevented an emergency tracheotomy
or even a worse fate. The loss of the lower lip and tissues of the chin is complete, while
the amount of mandible remaining is represented by the thinned and atrophied ascending
ramus of the right side, and by the ascending ramus, angle, and one molar tooth on the left.
The condition in January 1917, after the healing process was complete and the general
condition more satisfactory, is shown in fig. 314.

FIG. 313. Early condition.

Fio. 314. Healed condition.

At this stage the first operation, which took place on February 27th, 1917, was performed
under chloroform-oxygen anaesthesia in the sitting-position, administered by Lieutenant
R. Wade, R.A.M.C., at the Cambridge Hospital, Aldershot. The main features of the
operation were the freeing of the tongue and the making of the flap which formed the basis
of a new lip. The result, as far as it went, was satisfactory, as shown in fig. 318, but the
absence of the mental prominence as well as the loss of function, were left to be dealt with
until a later stage.

A serious attempt to bulge out the new " lip " by traction from a head-piece was made
in conjunction with Captain W. Kelsey Fry, M.C., at the time of this operation, but it was
badly tolerated and the result was not gratifying. In view of the general shortage of tissue,
plastic flaps from the neck or cheek were not indicated, and in view of the success of the
double-pedicled imbedded flaps and of the experience one has had of single-pedicled bridge-
flaps, it occurred to me that the employment of a double-pedicled bridge-flap from the scalp
would meet the case without fear of the blood-supply. By a bridge-flap is meant one in
which the pedicle lies over healthy skin, is divided from the grafted terminal portion after

INJURIES OF THE LOWER LIP AND CHIN

about ten days, and is then replaced into its original position. The double-bridge flap,
though I believe original, is merely the logical development of double-pedicle imbedded
and single pedicle bridge-flaps, and it combined the advantages of a double blood-supply
and of the provision of a flap well distant from the lesion.

In this particular operation, which took place on September 20th, 1917, at the Queen's
Hospital, Sidcup, Captain J. L. Aymard and Lieutenant G. C. Birt assisting, in which ether-
oil was given by the rectal method (Lieutenant R. Wade), the flap stretched from ear to ear
across the vertex and was about 3 inches in width. See fig. 320. Before bringing this into

Fio. 315. Showing amount of mandible lost.

FIG. 317. Stages in first plastic.

Fio. 316. First plastic : Freeing of tongue and advancement of
flap as beginning of new lower lip.

170

PLASTIC SURGERY

position, the skin below the buccal opening was raised by incision and dissection, and laid
on the upper surface of a large osteo-chondral graft from the seventh rib. This measured
some 6 inches along its long convex border, and was the shape of a boomerang ; it included
about 1 inch of the bony portion of the rib and was fixed by iron wire into the remains of
the jaw, bone to bone on the left side and cartilage to bone on the right, being fixed so that
the point of maximum convexity of the cartilage became the prominence of the chin. The
large scalp-flap was then swung over the face into position so that it covered the upper,
lower, and lateral aspects of the new " jaw," and sutured to the surrounding skin edges.

FIG. 318. After Brat plastic.

FIG. 319. Second plastic : Scalp flap on double
pedicle swung down over bone graft.

The pedicles were cut on the eleventh day and returned to the scalp (fig. 321) ; the new blood-
supply of the grafted portion being satisfactory, there was no question of gangrene.

Many causes operated against asepsis, of which the more obvious were : (1) the length
of operation ; (2) the difficulty of sealing off the junction of the pedicle and the imbedded
portion ; and (3) the very strong growth of hair on the flap. Discharge appeared at the
lower border of the flap on the fifth day, and has continued.

One must own that, in planning this operation, it was not expected that a good functional
result would accrue, but some degree of mastication is possible where there was none, and
the gain to the patient of having a chin and a full beard is almost certainly permanent. The
secondary disability is a bare area on the top of the scalp, which is being epithelialised.

In criticising this procedure the author feels it would be better either to insert a piece
of metal or celluloid at the time the scalp-flap is brought down, to be replaced later by an
osteo-chondral graft under more aseptic conditions, or else to imbed the graft in two halves
in the scalp some six weeks before it is swung down. In this event, the graft, at a later
stage, could be joined in the middle and to the remains of the jaw.

The cartilage graft, with its small attached portion of bone, continued to undergo
absorption from suppuration, until it had all absorbed. The wires and the sequestrum
were removed in February 1919.

The appearance now was very much inferior to that when the graft was giving shape

INJURIES OF THE LOWER LIP AND CHIN

171

to the chin, and the portion of scalp which had been grafted there had undergone a con-
siderable amount of wrinkling. The patient refused to grow a beard, which might have
camouflaged the defect, and unfortunately depilatory doses of X-rays were applied. This
led to a partial depilation only, and the resulting appearance of islets of hair surrounded
by white, lifeless-looking skin was a further disappointment. Since then two attempts
to remedy the man's condition have been made without any success ; and a third attempt
is in progress. But the general condition, lowered by the results of the injurv and long
period under hospital treatment, is such that the prospect is not very hopeful.

FlQ. 320. Second plastic : lateral view.
(Note pedicle.)

FIG. 321. Pedicles severed and returned.

172 PLASTIC SURGERY

CASE 76

This case was received in my clinic only three months after being wounded.

This patient, though not giving such a ghastly appearance in the early photograph
as the previous one, suffered a greater loss both of the bone and of the soft tissues. The
whole of the upper lip and the whole chin had been swept away, and the tongue was adherent
to the margin of the wound. The loss of bone in the mandible is very extensive, being,
however, just in front of the angle.

Three months after wound the first plastic was done. The dental officer in charge of
the case was Captain Hornyblower, working under Captain L. A. B. King, R.A.M.C. A
large vulcanite artificial chin was made and attached by a splint to the upper teeth, and
an attempt was made to make the new mouth over this.

The result was indifferent, and no attempt to remake the chin was carried out.

Had it been possible to have retained the appliance, a satisfactory mouth might have
eventually been obtained, but the swinging in of the flap on the left side had pulled over
the corner of the mouth to a very considerable extent. When all had healed up there was
considerable tension of the new lip, and, after consultation with the dental surgeon, it was
decided to remove the prosthesis. When this was done, it was thought necessary to close
the lower opening in order to prevent the dribbling.

The intermediate stage photographic records are missing. It consisted of the widening
of the mouth to the left, so that access to the buccal cavity could be obtained by the dental
surgeon, Captain W. Kelsey Fry, M.C., R.A.M.C., working in conjunction with Sir Francis
Farmer, who designed an appliance, next attempted to stretch forward the tissues of the
chin, which had now become softer and more amenable to traction. The patient, however,
was not particularly tolerant to this procedure, and I felt that perhaps one was wasting
time, and, after consultation with Sir Francis Farmer and Captain Fry, who advised one to
carrv out a more radical procedure for the building up of a new chin, the author obtained
from Lieutenant W. W. Edwards, the sculptor, a kind of chin in plaster, the size of a pros-
thesis necessary to make a chin over it. This was later cast in aluminium, and attached
by suture to the upper teeth, on which was a cap-splint. Around this artificial apparatus
was built an epithelial pouch, in the following manner. Three skin-flaps two being lateral
and one central from below were reflected and sutured, with continuous catgut, over the
middle raw surface outwards. These flaps were accurately designed beforehand in tinfoil.

The raw area thus created by the turning in of these skin-flaps, which included the
prominence of the new chin, was also accurately gauged beforehand, and a model cut in
rolled-out lead plate, to which were added the necessary pedicles, to carry a large double
pedicle scalp-flap down to the chin. The appearance of this flap is shown.

It all healed by first intention, the pedicles being carefully attached sewn skin-edge
to skin-edge.

The central portion of the scalp was skin-grafted, the Thiersch grafts being taken from
a tattoo mark in his right forearm, the idea being that the blue tattoo mark would show
less conspicuously than white skin. It is interesting to note that this mark contained the
letters " Bert," and up to the time of writing, which is six months after the operation,
the letters are still quite clearly legible on the top of this patient's scalp. The pedicles
were returned under local anaesthesia without difficulty, one of them being done for me by
Captain Waugh, U.S., M.R.C., and in the main operation I had the assistance of Major
Dorrance, U.S., M.R.C. The effect of this operation is to have produced an epithelial pouch
on the front of the man's neck. The back wall of this pouch is lined by the previously
existing lower margin of his mouth, which was not destroyed. It is intended to divide this
inner partition, to spread it along the margin of the new lip as a red margin. This will have
the effect of making the two cavities into one, and Sir Francis Farmer has taken a cast
which indicates these two cavities as they exist at present. It is intended to fit a combined
chin and lower denture to the remains of the mandible. No crinkling or retraction of the
grafted scalp-flap is occurring now three months after the operation and a satisfactory
beard could be easily grown. The patient, however, prefers to shave.

INJURIES OF THE LOWER LIP AND CHIN

173

FIG. 322. Healed condition : Front.

FIG. 323. Healed condition : Profile.

FIG. 324. After first plastic.

FIG. 325. Scalp flap on double pedicle brought down
over inturned skin flaps from cheeks and neck.

174

PLASTIC SURGERY

Fio. 326.

FIG. 327.

FIG. 328.
After return of pedicles : Front and side views. Prosthetic chin in position.

INJURIES OF THE LOWER LIP AND CHIN 175

Remarkable further progress has been made in this case in that into such a plastic chin
containing no musculature a new mandible has been successfully grafted. Also see opera-
tion notes. X-ray of the bone-graft is too late for insertion.

An excellent functional result has been obtained.

OPERATION NOTES

Gunner W , wounded France, 16.9.16, admitted 30.9.16. G.S.W. 2, 4, 8, 1, 9, 1.

Fracture through both horizontal rami just in front of angles, whole of intervening jaw
missing. On right side there are stumps remaining of M. 2. Left side M. 2 is involved.

4.12.16. Plastic operation (Captain Gillies). The main feature of this operation in
the attempt to form the mouth was that a local flap cut from the right cheek with its base
upwards, was swung down and placed over a large prosthesis and made to meet the whole
thickness of lip which remained at the left angle of the mouth. This was cut in a circular
fashion about half an inch from its mucous border to enable it to swing forwards. No
attempt was made to close over the large gap below. No relaxation sutures were used other
than catgut and deep silkworm in the flap itself.

8.3.17. Operation (Captain Gillies). A flap dissected up from left upper lip of cloaca
with its base at level of angle of mouth, inner edge being about 1 inch distant. Mucous
membrane along floor of mouth united to that lining edge of cloaca or region of flap. The
under surface of tongue was freed from the adhesions binding it down to floor of mouth.
Two strong silk-worm gut ligatures passed through substance of tongue and tied over metal
bar of bridge fixed on upper teeth, thus lifting the organ and preventing formation of further
adhesions. Skin freed along remaining upper lip of cloaca, freshened inner part of lip
twisted upon itself and sutured to base of tongue. Lower lip of cloaca freshened. A flap
raised by taking incision from the outer third of lip downwards and outwards to the right
neck at about the level of angle of mandible. Remaining portion of cloaca edge on left
side freshened and undercut, deep catgut retention sutures being used for anchoring the
large flap into its new position. Skin surfaces united with horsehair, thus entirely closing
cloaca. A vulcanite splint was fixed in position along floor of the mouth by means of sutures,
in order to supply contour over the chin region.

21.6.17. Small plastic operation on lip to enlarge mouth.

7.10.17. Transfer to Park Hospital, Hither Green. Scarlet Fever.

14.12. 17. Readmitted.

11.5.18. Operation (Major Gillies) for new chin and lower lip.

Method. Model of inside measurements of new chin made in cast silver and laid
over existing aperture (designed with the assistance of Lieutenant J. Edwards) and suspended
from the upper teeth. Over this chin-piece three skin-flaps (two lateral and one inferior)
were sewn over their skin surfaces towards the prosthesis which now lay in a complete
epithelial pouch. Sutured by catgut, with assistance of Captain H. C. Malleson, R.A.M.C.,
and Major Dorrance, M.R.C., U.S.A. The raw surfaces from which these flaps were taken,
as well as that which lay over the chin, were covered in by a double-pedicle scalp-flap, which
was swung over the face into position. In cutting the pedicles of this flap care was taken to
cut and ligature both the anterior and posterior branches of the temporal artery, so that the
main force of this blood-vessel should be directed into the pedicle. Both the inturned flap and
the scalp-flap were accurately cut to previously designed models and all fitted accurately.

Skin graft thigh to scalp, partial, and also tattoo-mark in arm transferred to same area.

Later. An osteo-periosteal graft from the tibia, seven inches in length, was wired
to the mandibular remains in September 1919. Healing was by first intention. The appear-
ance has not been altered.

Bony union has occurred at both ends, and a functional dental appliance fitted over
the new mandible, giving from 50 to 60 per cent, of normal mastication.

Figs. 329 332 illustrate a modification of the method of forming a chin used in
Case 76. It has been employed in two cases, both of which are as yet unfinished but
give every promise of an excellent result.

176

PLASTIC SURGERY

Fio. 329. Flaps for lining of new chin outlined.

Fia. 330. Lining flaps being inturned over a
prosthetic chin. Forehead flap outlined.

Fio. 331. Covering flap for chin being swung
down from forehead.

Fio. 332. Suture. Pedicles tubed.

INJURIES OF THE LOWER LIP AND CHIN 177

BONE-GRAFTING TO THE MANDIBLE

The reconstruction by bone of the missing portions of the mandible is the
ultimate aim in the great majority of severe injuries of the lower lip and mandible.
In quite a number of cases there is a much larger loss of bone than of the soft
tissues. These present no difficulties, and the operation for bone-grafting is
uncomplicated.

It is not proposed, in this volume, to enter at all fully into either the theory
or practice of this procedure. A rough outline of the principles is indicated
below, and the various methods that the author has adopted, or seen adopted
in his actual experience. The author was very strongly opposed in the first
two years of his experience to the use of any foreign body, such as wire or plates,
as a method of fixation. In this he was influenced by the work of Albee and
Lindemarm. In the early stages, the operation of bone-grafting was very
much on trial, and in these early days many cases were operated on too soon
after the healing of the wound, and frequently in tissues which were not suffi-
ciently vascular to tolerate the graft. The method of auto-fixation which was
adopted was exceedingly difficult, but a large number of cases of successful
rib-grafts were obtained in 1916 and beginning of 1917. The method of auto-
fixation was, broadly, the making of a hole in one' fragment and a peg on the
other fragment fit respectively into a hole and a peg of a graft. When this
fixation was satisfactory, the cases were most successful. Several of these
grafts have been examined two years after their insertion, and the function-
when the dental condition allows it is remarkably good.

One officer who had two inches of rib inserted (fig. 337) can crack a brazil-
nut. Owing, however, to a certain number of disappointments inseparable
from this method such as the breaking of the peg or of the fragment at the
last moment of the operation a number of these grafts failed, the graft being
absorbed, either by sepsis or aseptically.

Concurrently with this method the author adopted the osteo-periosteal
method advocated by French surgeons, but reserved it in the first instance for
gaps of small dimensions. The method was gradually extended to larger gaps,
and in the author's opinion it is specially suitable for grafts : (1) in newly made
soft tissues ; (2) in very large gaps round corners where one fragment is prac-
tically non-existent while the other is fixable by splints ; (3) where the fragments
can be maintained in position by dental splints that is to say, they bear sound
teeth which can be utilised for intra-oral fixation ; in this case the gap may
be quite short, as in a pseudo-arthrosis, or qviite large, as where the bone is
quite lost from molar region to molar region, a tooth remaining on each fragment,

178 PLASTIC SURGERY

It is also claimed by the French that this method can be utilised at a much
earlier date than a block graft. The author dissociates himself from this view
as he thinks it is unsound, although not disputing the possibility that osteo-
periosteal graft more readily forms bone in a septic wound than do the block
grafts. In all cases, a due interval should be allowed to elapse ; this interval
varies according to the condition of the tissues into which the graft has to be
placed and to the length of time that the case has remained septic after the
wound. The author is convinced that this method has a definite place in the
methods to be chosen for special cases.

Still adhering to the principle of auto-fixation, the author went to the
tibia for losses in the region of the angle of the mandible in which it is desirable
to replace and maintain the posterior fragment as far back as possible. In
order to do this, specially shaped blocks of tibia were laboriously fashioned to
make an accurate reconstruction of the angle and missing portion of the body
of the bone. On the posterior end of the graft was usually left a peg of bone
which was fitted up a canal made in the medullary cavity of the posterior frag-
ment. The anterior fixation Avas made by similar but smaller wedging or by
a bone-peg. The X-ray of two such examples is amongst the series shown.
The method is very interesting, and exceedingly good when successful. It is,
however, much too difficult to perform, and requires an operation lasting some-
times over three hours. The graft also has to be handled considerably in order
to make it fit accurately. Other disabilities of the method are that accidents
with the graft are liable to occur in taking it from the tibia, and in several cases
the shaped graft after its removal from the tibia --was split at some part.
Two good examples are shown in figs. 346 and 348. A third is shown in fig. 350 :
in this, however, the shaped graft, taken from a brittle tibia, broke twice before
its shape was complete. In fitting in the remains into the recesses made for
it in the fragments, the fragments broke. As a last resort the graft, now whittled
down to a thin plate of compact bone, was wedged into the fragments at each
end and retained there by a silver wire passed from one fragment to the other
without passing through the graft. The result was strikingly good, a most
solid bony union occurred despite the various disasters that had happened.

The pedicle bone-graft, as advocated by Cole, was adopted in a certain
number of cases, one or two examples of which are shown in figs. 352 and 354.
The operation is easy to perform, is not liable to sepsis, and is a method of choice
for certain types. It would, however, appear to have no real advantage over
the plain block-graft from the ilium. Its disadvantages would appear mainly
to be : (a) that the union is liable to be springy as it occurs only along the lower
border of the mandible and no regeneration of the bone-tissues of the alveolar
portion occurs ; (b) if used in large gaps one is apt to get insufficient apposition

INJURIES OF THE LOWER LIP AND CHIN 179

of good bone between the graft and the mandible ; (c) cosmetic-ally, it is in-
different ; (d) a query is also raised as to whether the taking of the lower border
from the healthy part of the mandible may not unduly weaken that portion,
especially when absorption of the alveolar bone occurs after the teeth come out.

It is a very easy operation to perform for a loss of bone occurring in the
middle of the body of the mandible ; but its advantages even in this simple
type of case do not outweigh its disadvantages, and it would not appear to give
better results than the straight ilium block operation.

For large gaps, Lieutenant-Colonel H. S. Newland, D.S.O., A. A.M. C.,' had
advised the use of combined pedicle and block-graft. A small pedicle bone-
graft is fixed to the main graft in the centre of the gap with the idea that the
osteogenetic process should commence in the middle as well as at the end of
the graft. The principle seems sound, and is an improvement on the Cole
pedicle graft, in that it regenerates bone not only along the lower border but
also up towards the alveolus.

The next stage in the hisbory of bone-grafting was the use of block tibia
and ilium grafts of simple character, wired into position between the frag-
ments. The adoption of this method by the various surgeons in the Queen's
Hospital, Sidcup, was generally due to Sir Arbuthnot Lane. It is so simple
and successful that little interest remains in the operation, and provided that
no concealed sepsis is lit up by the operation, .110 cases of failure to obtain
bony union are now reported.

The Author's Method. Indications : where the loss of bone includes the
whole of the ascending ramus, such as occurs after excision of the mandible
for tumour. A piece of the seventh or eighth rib taken from the opposite
side, including the costochondral junction and the point of maximum convexity.
The bony portion of the graft is wired to the freshened anterior fragment. The
maximum point of convexity forms a new angle of the mandible, while the
ascending ramus is represented by that portion of costal cartilage which runs
upwards to the sternum. A false joint in the neighbourhood of the glenoid
fossa is thus made, and a cosmetic and functional result accrues (figs. 333-335).
The author also undertook a number of bone-slides where attempts were
made to interpolate partially or completely detached pieces of bone from the
end of a fragment into the gap between the two.

A few of these were successful, but the majority ended in non-union, owing
to the fact that insufficient freshening of the eburnated ends of the fragments
had been made.

A simpler method than this has been adopted by Billington. The surfaces
of the fragments are freshened and a split rib laid over the gap and the two
fragments with a considerable overlap. The soft tissues are merely sutured

180 PLASTIC SURGERY

over this m-aft. When all is healed, the case is handed to the dentist, who

fixes the necessary splint. In all previous methods the mandibular fragments
are fixed as far as possible in a correct position prior to operation. Billington's
method has the virtue of simplicity, but can have no place as a method of
controlling the edentulous fragment.

It is practically agreed that the posterior fragment, when once it has swung
forward, which it does in the vast majority of cases, cannot be controlled satis-
factorily by any intra-oral method. The pressure of the apparatus necessary
to do so, in my experience, invariably causes pain, discomfort, and ulceration
of the mucous membrane over the ascending ramus. In such cases it is essential
to insert a block of bone which will, by its length, press back the posterior
fragments. Adequate fixation, either by wire or wedging, must also be provided,
so that the posterior fragment is maintained there.

Summing up the present position of bone-grafting of the mandible,
therefore : (1) The main source of bone should be the ilium. The fragments
of the mandible should be maintained in their normal positions either by
intra-oral apparatus, or by the graft. The method of fixation of a block-graft
should be by wire. Some degree of auto-fixation on the edentulous displaced
posterior fragment is desirable. Union is more rapid when the graft overlaps
the fragments either on its inner or its outer aspects. (2) The osteo-periosteal
graft is indicated in very large gaps, in very small controlled gaps, and in
tissues the blood-supply to which is poor. It is also useful for bony losses in
the symphysis region where a marked curve is required. (3) Pedicle graft
(Cole), combined with a superimposed block-graft (Newland), is an alternative
and a very sound method of the plain ilium graft. (4) Billington's late fixation
method no doubt has a place in cases where loss is minimal and where there
is but slight and easily remediable deformity ; but the many late results of
this method seen by the author do not encourage one to adopt it as a routine.
(5) The autologous osteochondral graft (author) has not a large place in war
injuries, but is the only method yet evolved to cope with the condition resulting
from the removal of half the mandible in civil practice. In one such case its
adoption has resulted in a marked cosmetic improvement, and also a small
improvement in function due to the provision of an extra point d'appui for the
symphysis. Explanatory diagrams are given.

INJURIES OF THE LOWER LIP AND CHIN

181

Fio. 333. The defect.

FIG. 334. The opposite eighth or seventh rib
the sourco of the graft.

Fio. 335. Graft in position.
THE AUTHOR'S OSTEOCHONDRAL GRAFT.

182 PLASTIC SURGERY

The skiagrams which follow arc selected from among a very large number
of cases as being fairly typical of the various methods discussed in the preceding
pages.

For the most part they require no description, the condition being in each
case evident to the practised eye.

After there is firm union it can nearly always be made possible to fit a
denture, by employing the author's modification of the Esser Inlay operation
to recreate the labiogingival sulcus, as described in the chapter on Principles.
This was achieved even in Case E, though here, as is usual in such terrible cases,
the denture is a cosmetic rather than a functional triumph the paucity of
teeth precluding any attempt to fit a masticatory appliance.

No example is shown of an osteochondral graft, as the major portion of
the graft, being cartilaginous, throws no shadow, and the skiagraphic appearance
presents nothing peculiar to this method.

INJURIES OF THE LOWER LIP AND CHIN 183

Fio. 33G. Case A. (Rib graft.)

Fio. 337. Case B. (Bib graft.)

FIG. 338. Front. F IG . 339._Lateral.

Case C. Osteo -periostea! graft from tibia.

PLASTIC SURGERY

Fio. 340. Case D. (26.8.18).

FIG. 341. Case D. (7.11.18).

FIG. 342. Case D. (7.11.18).
Osteo-periosteal graft from tibia.

INJURIES OF THE LOWER LIP AND CHIN

185

FIG. 343. Case E. (1.10.18).

FIG. 344. Caso E. (7.7.19).

FIG. 345. Caso E. (7.7.19).
Oeteo-periosteal graft from tibia.

186

PLASTIC SURGERY

Fid. 340. Case F.
(The oivli of tho fragments are outlined with dots.)

FIG. 347. Case F. (Tibial Block.)

Fio. 348. Case G. Tibial Block. (12.2.18.)

FIG. 349. Case G. Tibial Block, (10.12.18.)

INJURIES OF THE LOWER LIP AND CHIN 187

Fia. 350. Case II. Tibial Block. (20.0.18.)

Fio. 351. Case H. Tibial Block. (3.7.19.)

Fio. 352. Case I. (8.8.18.)

FIG. 353. Case I. Pedicle graft. (15.11.18.)

188

PLASTIC SURGERY

FIQ. 354. Case J. (14.8.18.)

FIG. 355. Case J. Pedicle graft. (18.12.18.)

Flo. 356. Case K. Lateral. (14.1. 18.)

Fio. 357. Case K. Ilium Block. (14.11.18.)

INJURIES OF THE LOWER LIP AND CHIN 189

Fio. 358. Case L. Major Chubb's case.

FIG. 359. Case L. Ilium Block.

Fio. 360. Case M. Ilium Block.

PROSTHESIS AND PALATES

CHAPTER V
PROSTHETIC APPLIANCES IN RELATION TO PLASTIC SURGERY

IN the treatment of injuries of the face, with laceration or destruction of the
soft tissues, with or without loss of the bone, it is the aim of the plastic suigeon
to replace the tissues to their normal position and so restore the contour of
the face. When these injuries involve the tissues of the oral cavity with con-
sequent loss of teeth, the surgeon has the additional aim, in his treatment, of
maintaining the mouth in such a condition that the patient will later be able
to wear a functional denture. In the attainment of this aim in the treatment
of many of the cases, the surgeon has a valuable aid at his command in the use
of prosthetic appliances that is to say, mechanical means of maintaining the
hard tissues in their correct alignment. These prosthetic appliances are usually
made by a dental surgeon working in the closest. co-operation with the plastic
surgeon, and it must be borne in mind that the appliances, to fulfil their objects
successfully, should be of simple construction, removable as far as possible, easily
kept clean by the patient, and in some cases of value in mastication as well.

The appliances which may be of service are so numerous and varied that,
for the purposes of description, it is necessary to classify according to regions
the injuries which necessitate their use.

1. Those involving the oral cavity ;

2. Those involving the nose ; and

3. Those involving the eyes.

Injuries involving the oral cavity are frequently complicated by fractures
of the maxilla or the mandible, with or without loss of bone, but it is not intended
here to describe the treatment of such fractures except as they affect the work
of the plastic surgeon. It is advisable that this class be further subdivided
as follows :

(a) Without loss of bony tissue, and

(6) With loss of bony tissue.

(a) In dealing with cases in which there is no loss of tissue, the main object
of the prosthetic appliance is to maintain, in their normal positions, such parts of
the hard or soft tissues as may have been displaced by the injury, and to prevent
the gradual obliteration of the dental sulcus by adhesions, the latter object
being of the greatest impoitance in the future fitting of dentures.

13 103

194

PLASTIC SURGERY

fragments of hard tissue are brought into alignment and the
eonouaincS by means of a simple dental splint, sin .lar to^ ho
in fig. 361, and when these cases involve laceration of the soft

FIG. 361. Simple dental splints.

are likely to obliterate the dental sulcus, removable vulcanite flanges are fitted
to the splint, as shown in fig. 362, to prevent the soft tissues encroaching upon
and destroying the sulcus. When there is only laceration of the soft tissues

a similar appliance or a denture with exaggerated
flanges is used for the same purpose.

There are many variations of the use of
flanges attached to splints or dentures ; the
upward support of a lacerated and drooping
upper lip may be taken as a typical example.

A distinct type of case sometimes met with
j s that of a marked deformity of the upper part
of the face, but without loss of bone, due either to a complete horizontal
fracture of the maxilla with a backward displacement, or to a complete
vi-itical fracture with overlapping of the fragments, resulting in the falling in
of the soft tissues, which gives the appearance, on a casual examination, of a
case with loss of hard tissue. To restore the contour of the face, it is necessary

Flo. 362. Splint with flange to preserve

dental sulcus.

PROSTHESIS AND PALATES

195

to reduce the deformity of the hard parts, and for this purpose an apparatus
first used by Major Rishworth, N.Z.U.C., has proved of great value. This
appliance, as shown in fig. 863, consists of a headpiece attached by two vertical
bars to a splint on the teeth of the mandible, the latter being fixed in the slightly
open position. A splint is also fixed on the displaced fragment of the upper
jaw, and the necessary forward tension is produced by means of screws attached
to the vertical bars. In some such cases of overlapping, it is advisable to reduce
the displacement surgically, and to
hold the fragment in good alignment
by means of simple dental splints.

When there is only a loss of the
soft tissue of the lips, etc., the neces-
sary prosthetic appliance consists of a
dental splint carrying a removal flange
moulded in such a way that the plastic
surgeon is enabled to build the new
lip over it, maintain the correct con-
tour, and form a new dental sulcus.
In cases of extensive loss of the soft
parts of the cheek, it is not only neces-
sary to make a flange over which to
build the soft tissues, but the jaws
must be fixed in the position of the
open bite, to prevent any trismus re-
sulting from the contraction of the
scar tissue.

(b) In many instances there is a
loss of hard tissue in addition to that
of soft tissue, such as the loss of the
pre-maxilla. This loss must be replaced

by a prosthetic appliance as shown in fig. 364, for the purpose of maintaining the
remaining bony tissue in its correct alignment, and to enable the surgeon to
restore the soft tissue in its correct fulness and contour. When the loss of bone
of the mandible is very extensive, the fragments are maintained as far as possible
in their correct positions by dental splints while awaiting a bone-graft operation.
This applies particularly to the posterior fragment, which if not so maintained
will cause a marked deformity by the falling in of the soft tissues in the region
of the angle. A dental splint is also worn during and after the bone-graft
operation, to immobilise the fragments and graft and to preserve the teeth in
good occlusion. For this purpose splints are fitted to the teeth of the upper and

FIG. 363. Apparatus for forward replacement of
maxilla.

19(5

PLASTIC SURGERY

lower jaws and fastened together with a screw or some such mechanical device.
When there are teeth on both fragments of the mandible, no difficulty is ex-

FIG. 365. Patient for whom the apparatus in pre-
ceding figures was made. See also Case No. 62f> in
section on Upper Lips (p. 87).

Fio. 364. Prosthetic replacement of pre-maxilla.

perienced in immobilising them. Such
is not the case, however, when there
is a small and edentulous fragment.
Many attempts have been made to
hold this fragment in position by
means of a flange fixed to the lower
splint, but the best results have been
obtained by bringing down the pos-
terior fragment at the time of the
operation and fixing it by means of
the graft. Early movement has been
advocated and found efficient in these
cases, and to facilitate this movement in instances where it is impossible to fix
both fragments mechanically with a splint, it has been found of great value to
have a guiding flange fitted on to the splint
on the larger fragment, as shown in fig. 366, so
as to prevent the tendency of this fragment to
swing towards the smaller fragment, and thus
put unnecessary strain upon the newly im-
planted graft. By this means, movement can
be started earlier than if the flange had not
been fitted.

With reference to the importance of pre-
venting the encroachment of the soft tissue
upon the dental suleus, and the consequent
inability to fit satisfactorily a functional den-
tare, many cases have come under notice in

PROSTHESIS AND PALATES

197

Fid. 3G7. Splint with flange to maintain Stent in position,
for the Epithelial Inlay.

which it has not been possible to prevent this encroachment during the early
stages of treatment, and these cases for some time presented a difficult problem,
which was exaggerated in many instances by the resultant falling in of the
soft tissues. The first attempts to reform the sulcus were by freeing the soft
tissues from the hard, and immediately fitting a splint or denture with an
exaggerated flange to push out the soft tissues. The results of this method
were far from encouraging,
adhesions gradually taking
place again. Recently, a
more successful method has
been evolved by the Tise of
the epithelial inlay : opera-
tion (modified Esser). For
this operation a prosthetic
appliance is required for the
purpose of holding the Stent
in position for the necessary period. As shown in fig. 867, this appliance
generally consists of a metal cap splint with a removable horizontal flange so
fitted as to maintain the Stent in position, and to keep it in close contact with
the surrounding tissues to enable the epithelium to become adherent. In the
after-treatment of these operations it is very important to remember that at
no time should the newly made sulcus be left empty, and, after the removal
of the Stent, a denture carrying the necessary prolongations must be immediately
inserted, and should be worn continuously for at least three months, after
which time experience has shown these results to be permanent. In the event
of loss of hard tissue in these cases, the denture is made to carry excessive vul-
canite to enable the soft parts to be restored to the normal contour. This
would not be possible in many cases unless the sulcus had been reformed by
an epithelial inlay, as the pressure exerted by the soft parts would make the
denture unstable and functionless.

Exaggerated cases of this type often present themselves. The extensive
loss of the anterior portion of the maxilla having resulted in a considerable
falling in of the soft tissues, a marked deformity of the profile of the face is
caused. The following cases are typical :

1. Private M

. On admission, it was found that he had an old gunshot wound,
with large loss of the maxilla and nasal structures and loss of both eyes. The hard palate
was entirely lost except for a small part, which included the two posterior tuberosities with
the intervening part of the palate. Both antra were widely opened, owing to the absence
of the nasal and anterior walls. The soft tissues of the lip and nose were adherent to the
small remaining part of the palate as shown in figs. 368 and 369. The case was seen by Major
1 For details of Stent and Epithelial Inlay see pp. 10 and H.

198

PLASTIC SURGERY

FIGS. 368 and 369,-Extensive bony loss.

FIGS. 370 and 371.- Prosthetic replacement of loss,

PROSTHESIS AND PALATES

199

Gillies, who decided to free the soft tissues from the small remaining part of the palate.
The anaesthetic was given through a laryngotomy tube. A knife was inserted behind the

FIGS, 3 a and 373. Showing bony loss and prosthesis to replace it.

upper lip, and the line of attachment of the soft parts, both to the hard palate and laterally
to the remains of the superior maxilla, was divided
in a vertical direction until the level of the eye-
sockets was reached. The soft tissues were then
stretched forward. At this stage the case was
taken over by the dental department for the soft
parts to be kept in the new position. With the
patient still under the anaesthetic, dental com-
position was forced up into the gap made and
left to harden. When .hardened it was removed
and the impression used for making the necessary
permanent apparatus. In the meantime another
piece of composition was inserted into the gap
and left in position to hold the soft parts out while
the apparatus was being made. In this case no
epithelium was used to line the new cavity, and
great difficulty was experienced in permanently
maintaining the soft tissues in their position, and
it was only after various mechanical appliances
had been constructed to force the soft tissues
forward that a happy result was obtained.

2. Private P . This case was similar to

the above, but the loss of bone was not so great
(see figs. 372 and 373). The operation performed
was similar, except that a small Thiersch skin-
graft was placed upon the Stent, and round the
orifice of the cavity made, the cavity itself not FIG. 374. Result of replacement.

PLASTIC SURGERY

being lined. Here, again, great difficulty was experienced in keeping the soft tissues in
their places, although not to such an extent, as in the former case. Fig. 373 shows the
denture with a prosthetic replacement of the bony tissue lost.

3. Lieutenant W . As in the case of Private M , there was a very extensive loss

of bone. Before this patient came under treatment he had undergone repeated operations
for closing off the oral cavity from the remains of the nasal cavities, which had been entirely
Muvcssful. At the same time he presented the marked deformity shown in fig. 86 (p. 2C6),
and it was impossible to reform the nose to a satisfactory result in that condition. Moreover,

the fitting of a really functional denture
was not possible. Judging from the ex-
perience of the above cases, it was decided
to reopen the passage between the mouth
and the nasal cavities and replace the loss
of bone by a prosthetic appliance. The
operation performed was the same as in
Case 1, except for the important difference
that the whole of the cavity was lined by
means of a skin-graft, the cavity pre-
senting a white appearance due to the
epithelial lining (vide fig. 375). The result
was more than satisfactory, and at no

time has there been any difficulty in
keeping the cavity open. It is interesting
to note that, with the passage of time,
the implanted epithelium becomes pinkish,
and approximates more and more closely
to mucous membrane.

These cases emphasise the fol-
lowing points :

1. The necessity of restoring
loss of bone by a prosthetic appliance
before attempting plastic operations upon the soft parts ;

2. The great advantage of the epithelial inlay operation over the old method ;
and

3. The great aid, in making a functional denture, of having a certain amount
of support from the prosthesis replacing the lost bone.

In none of the above cases was it possible for the patient to wear a denture
before the operation had been performed. At present they are all wearing an
efficient appliance.

Fio. 375. Cavity lined by Thierscli graft.

INJURIES INVOLVING THE NOSE

In the treatment of cases of laceration of the soft and hard tissues of the
nose, with or without loss of such tissues, it is often necessary to restore the
replaced tissues to their correct position by prosthetic appliances. The ap-

PROSTHESIS AND PALATES

201

pliances which may be used are

very varied, but generally speaking

are of two classes :

(a) Intra-oral, using the teeth

as the point d'appui ; or

(6) Extra-oral, i.e., where a

headpiece is used for purposes of

attachment.

Wherever possible, intra-oral

appliances are preferable, owing to

the difficulty experienced in obtain-
ing complete stability by fixation

to a headpiece and to the discomfort

often caused by the pressure upon

the head exerted by headpieces.
(a) Intra-oral appliances.

Fig. 376 illustrates a typical

apparatus used to support the

lacerated portions of the tissues

after surgical replacement, which no. 370.-^! splint with dental fixation.

has been found very successful. It should be remembered, however, that

this appliance should not be used to exert pressure upon the soft parts,

but merely for the purpose of supporting them in their correct positions.

Too much pressure will only lead to ulceration, and failure will result.

In instances where the bridge of the nose has been depressed, and the tip

of the nose has been displaced upwards, the surgeon calls for an appliance to

hold the nose in its correct position
after it has been freed. Fig. 377
illustrates a typical appliance used
for this purpose. The piricer-like
portion holds the columclla, and
the necessary downward and for-
ward pressure is exerted by means
of attachment to a splint fixed to
the teeth of the upper jaw.

In cases of lateral displacement
of the nose a very similar appliance

FIG. 377 Adjustable nasal splint with dental fixation. ^ Q ^^ shovfn m fig> 377 is use d,

pressure in these instances being exerted in the necessary direction by a vulcanite
pad being placed either in the nasal cavities or on the external surface of the nose.

PLASTIC SURGERY

Fio. 378. Adjustable nasal splint with extra-oral fixation. FIG. 379. Obstructed airway due to loss of columella.

Fios. 380 and 381. Airway restored by prosthesis.

PROSTHESIS AND PALATES

203

(b) Extra-oral appliances. As mentioned above, this type of appliance
is used only in cases where intra-oral appliances are not possible, owing to an
edentulous or fractured upper jaw.

Fig. 378 shows a type of appliance which was used to support the depressed
bridge of the nose. The nose was
surgically raised, two soft rubber
plugs inserted in the nasal cavities,
and attached to the appliance by
means of silk brought out through the
skin of the nose. Through a screw
attachment pressure was brought to
bear to hold the soft parts in the
required position. This apparatus was
elaborated for Major Gillies by his
American colleague, Captain Ferris
N. Smith, R.A.M.C. It will be noticed
that the necessary support is obtained
from three vulcanite pads, acting as
a tripod upon the forehead and cheeks,

thus obviating the discomfort caused by the wearing of tight bands round
the forehead, and being a distinct improvement upon the Carter bridge system
of support.

In figs. 379, 380, 381, and 382 is shown how, in the absence of a columella,
a prosthetic appliance can be fitted, which cariies out the double purpose of
maintaining the airway and improving the appearance, without being unduly
noticeable.

FIG. 382. The artificial columella.

INJURIES INVOLVING THE EYES

No prosthetic appliances are of any assistance in the early treatment of
injuries in this region, except in cases where they are associated with fractures
of the maxilla, involving the orbital plate. In these latter cases the maxilla
is often displaced downwards, and the prosthetic appliance used for raising the
upper jaw also supports the orbital contents, and tends to keep them in their
normal position.

When it is necessary to epithelialise the orbital cavity, a prosthetic appliance,
as shown in fig. 383, is required to hold in position the Stent used in this operation.
It consists of a vulcanite cup so shaped as to cover the Stent and hold it in
position by attachment to a splint on the teeth of the upper jaw. After the
removal of the Stent, it is necessary to make a vulcanite duplicate of it, and

204

PLASTIC SURGERY

this also is maintained in position by the same appliance until such time as the

artificial eye can be fitted.

Cases are often found in which the plastic surgeon is able to reconstruct the

soft tissues round the eye, so that the
patient, who was unable, prior to the
operation, to wear an artificial eye, is
enabled to do so. But although he be able
to wear the eye, it is sometimes impossible
to reconstruct the eyelids, especially the
upper, so that the eye bears the natural
appearance. In these instances, a great im-
provement can be effected by the construc-
tion of an artificial eyelid, with eyelashes,
attached to the artificial eye, which is held
by the newly-made socket. It is also pos-
sible, in some instances, to affix a ridge on
the outer surface of the artificial eye in such

Fia. 383.- Appliance used in epilhelialisation of a way that it will Support a dl'OOping Upper

eyelid, and so enhance the cosmetic effect.

Figs. 384 and 385 illustrate an apparatus (hardly prosthetic perhaps) used for

protecting a recently-sutured palate from the movements of the patient's tongue.

The above instances illustrate some of the valuable seivices rendered bv

Fics. 384 and 385. Apparatus to protect sutures from patient's tongue after closure of palatal deficiency.

prosthetic appliances in plastic surgciy, and the extensive and varied nature
of such appliances. Ihe apparatus mentioned in this chapter are described
as generally as possible, but it must be borne in mind that a critical consideration

PROSTHESIS AND PALATES 205

of the nature of the injury and the exact result aimed at is necessary in each
case. Scrupulous care must be exercised in the adjustment of details, if the
greatest possible benefit is to accrue from an appliance. Thus, there are many
slight variations of the same appliance, each of which augments the utility of
the apparatus in the successful treatment of injuries, similar in class but varying
in detail.

It must also be borne in mind that it is essential that there should be the
closest co-operation between the plastic surgeon and the dental surgeon who
is to make the prosthetic appliance. In most cases it is necessary to consider
both the surgical and the dental aspects, and it is only by working together
that the best results can be obtained. W. KELSEV FRY.

INJURIES TO THE PALATE

Asa result of a study of a long series of cases treated in conjunction with
Captain Kelsey Fry, M.C., R.A.M.C., and a development of the application of
the Esser inlay principle, the author has come to the conclusion that the problem
in palatal injuries can be much reduced. The essential problem here is the
question of mastication : Is the condition of the parts such as permits the ap-
plication of the most efficient dental appliance ? The author is convinced
that the existence of abnormal oronasal communications is not a serious dis-
ability ; it may even prove of immense service in the provisional support for
a prosthesis. Provided that the perforation is accurately occluded by the
appliance, it is found that the nasal cavity and antra are sufficiently protected,
and that speech and deglutition are restored to normal.

In one case of a perforation involving both antra, Captain Fry advised
Major Seccombe Hett, under whose care the case was placed, to enlarge the
perforation so that a purchase for the denture might be obtained from within
the antra. The result was very satisfactory.

Further to emphasise the supreme importance of the dental aspect in the
treatment of palatal injuries, a case is quoted in which the author has actually
re-created an oronasal communication which had been overcome previous to
the patient's admission, with the definite object of furnishing support for a
denture.

Lieutenant W- had sustained a total loss of nose and pre-maxilla (see
also p. 200), and the palatal gap had been cleverly bridged in the remaking of
the upper lip, which now hung from the anterior edge of the remnant of the
palate.

It was not found possible to fit a functional denture. The first step, there-
fore, was to free the lip from its new attachment. This led to a ringlike raw

200

PLASTIC SURGERY

area, which was epithefialised by a Thicrsch graft held in position by moulded
Stcnt fixed to a temporary appliance. Into the resulting intranasal prolongation
of the buccal cavity a prosthesis was fitted, made in three pieces of vulcanite,
and an efficient denture was made to take origin therefrom. An excellent
functional result went hand-in-hand with a notable improvement in the ap-
pearance (figs. 386 and 387).

As in all facial injuries, a successful repair in this region depends on meti-
culous care in the diagnosis. The loss in each layer of the palate, and the direc-
tion of any displacement together with the factors which maintain it, must
be accurately determined by oral, intra-nasal, and radiographic examination.

FIG. 38f>. Soft tissues adherent to remains of
palate after closure of oronasal communication.

Fio. 387. Oronasal communication restored.
Prosthetic replacement of bcny loss.

These injuries bear a superficial resemblance to congenital deformities, but
the problem is essentially different. There is actual loss of hard tissue, not
mere failure of union ; and mastication, rather than speech and deglutition,
is the first aim in repair.

The first consideration, therefore, is the provision of a dental appliance
which must not merely replace the structural loss, but should ensure efficient
mastication.

From the standpoint of treatment, these injuries may be divided as follows :
1. Those involving chiefly the pre-maxilla and alveolar border.

Ixperience has shown that these cases are, in essence, in the province of
the dental surgeon. Certain important preliminaries may have to be completed
by the plastic surgeon before the case is handed over. For instance, an adherent

PROSTHESIS AND PALATES 207

lip or cheek may require liberation with epithelialisation of the resulting raw
area, before the dentist has any chance of fitting a masticatory appliance.
Cases also occur where an ill-advised closure of a palate gap has been performed,
and the surgeon is faced with the repellent necessity of undoing the good work
of his predecessor, in order that the task of the dentist may be rendered possible.

2. Injuries leading to large or small hard-palate perforations, which do
not involve the alveolar border.

Here the surgeon feels justified in attempting closure. The intact alveolar
ridge gives promise of adequate support for any denture which may be indicated :
there is no need of the mechanical advantage offered by the perforation.

3. Lateral anterior defects involving the alveolus. Here the disposal of
the case rests on the question of the existence of teeth on the fragments bordering
the gap. If good teeth are present on both edges, closure may be undertaken
in the knowledge that the dental surgeon has adequate support for the application
of a masticatory appliance.

If teeth are lacking a condition usually co-existent with a levelling of
the alveolar ridge then there is need of any and every nook and cranny as
possible purchase for the denture, and since mastication is the prime necessity,
the surgeon must limit himself to the dental needs of the case.

4. Injuries involving the soft palate. There need be no hesitation in
repairing soft-palate injuries forthwith. The mobility of the part precludes its
being of use as a point d'appui.

Methods of repair used. So varied are these injuries in quantity and degree,
that few methods, both classical and those hitherto unknown, have escaped
a thorough trial, including at least two methods believed by the author to be
original. Lane's double-flap method has given good results in the author's
hands, where flaps have been available, and the Von Langenbcck principle
has proved satisfactory in cases where the state of the parts permitted the
advancement.

The author has seen cases of successful results from the use of large mucous
membrane flaps from the cheek. In selected cases, these would seem to be
ideal.

Working in conjunction with Major Seccombe Hett, the author has on
several occasions made use of the inferior turbinate as a partial or complete
obturator. This bone is separated from its attachment in part of its length
and is swung down on the pedicle of what remains.

Its double covering of mu co-periosteum makes it peculiarly adapted for
the purpose, and its phenomenal blood-supply enables it soon to establish con-
nection with the rawed edge of the palate. Its attached end can be safely
severed in about ten days, and brought down to assist in the closure.

208 PLASTIC SURGERY

The author has applied his tube-pedicle method in this connection, and
large perforations have been closed with skin from the neck and chest by this
means, in cases where coincident cheek loss has permitted the intrusion of the
pedicle. Indeed, if need be, it is probable that there is no gap which could not
be closed by this method. Were closure imperative, access for the pedicle
could be obtained by temporarily enlarging the mouth.

Summarising, therefore : First, a critical examination, with a view to
accurate determination of the loss, then a consultation with the dental surgeon
as to the advisability of surgical interference. (Shall the defect be covered,
left alone, or even enlarged ?) And, finally, a consideration of the surgical
possibilities of closure, bringing under review the approach to the injury, the
flaps available, the viability of the parts involved.

INJURIES OF THE NOSE

CHAPTER VI
INJURIES OF THE NOSE

IT is not proposed to give a full historical outline of rhinoplasty. Noses have-
been made since the very earliest times, and most of the methods possible
and impossible have been tried on isolated cases. No one man has ever,
previously, had sufficient material to elevate this branch of surgery from its
unfavourable status, which has been so aptly summed up by the French in their
saying " before he was horrible : now he is ridiculous." Artificial noses have,
therefore, been developed to a far greater extent in the past than has the operation
of rhinoplasty. How is it, then, that one is now in a position to state that in any
given case of rhinoplasty it is probable almost certain that, following operative
procedures, the patient will have a result that looks like a nose one that has good
circulation, good colour, and a good airway ? The answer is manifold.

The ravages of war have enabled a large number of cases to be collected
under one team of surgeons. The various methods have been tried and sifted
until a satisfactory combination has been developed.

The great principle of providing all three elements of the nose skin, support-
ing structure, and epithelial lining has been enunciated. In order to arrive at
a satisfactory reconstruction, diagnosis must be made of the independent loss of
each of these three elements. When it is known exactly what there is to replace,
both in quality and quantity, the problem of the restoration becomes simplified.
Among the following cases arc shown some good and some bad results.
The first entire nose constructed by the author was lined with mucous membrane,
without realising that it had been done. The next nose was made without
such lining, and the unfortunate result led one to seek the cause of failure. From
that day no nose, or portion of a nose, has been made here without its adequate
skin or mucous lining, and the whole status of rhinoplasty, as practised by
author and colleagues, has since that day undergone a change which is truly
remarkable. Although the necessity for this nasal lining was recognised quite
independently, one must pay great tribute to the rhinoplastic work of Kcegan
in India. For the Indian type of mutilation (where an unfaithful husband or
wife is punished by cutting off the soft parts of the tip of the nose) Keegan and
his follower, Smith, designed exact inturned flaps to line the tip and the alae.

The author had recognised that all noses must be skin-lined, but on digest-
ing Keegan's written work one was absolutely convinced that this is the right
principle. His particular flaps are applicable only to the loss of the lower third,
or fleshy part of the nose. But the principle has been extended and modified until
all types of loss can be successfully restored. Prior to this review of the Keegan-
Smith operation, the author had been confronted with a very great difficulty in
the " pug-nose : ' deformity. After several failures, one was fortunate enough

211

PLASTIC SURGERY

to evolve a principle which not only produced a definite cure for this deformity,
but is also applicable to many other restorations. This particular flap has been
fully described in the chapter on Principles. So much for the lining membrane.

In regard to the supporting structure, free cartilage implantations, both
autologous and homologous, are freely used. The cartilage may be put in
prior to the rhinoplasty, in either the external flap or in the internal flap, or
it may be interposed between the two flaps at the time or subsequent to the
rhinoplasty. The best time for such implantation varies with the type of case,
but the author is convinced that the imbedding of the cartilage in the flap that
is to make the external covering is an entire mistake.

Occasionally the best result will be obtained by implanting the cartilage

Fio. 388. Diagram to show the author's skin-
cartilage awing to replace and retain the tip in position,
and to provide skin-lining for the bridge and alse.

FIG. 389. Position of the skin -cartilage flaps after
they have been reversed. Tube-pedicle chest-flap is
represented on its way to the nose.

between the lining and the skin-flap at the time of rhinoplasty ; but the author's
principle of imbedding the desired cartilage in the inturned flap seems the most
scientific and best method. It is nearly always necessary to superimpose
further cartilage at a later date. This must be done with great care, as on one
occasion a very good nose was spoiled by unduly stretching the new skin. The
other method employed by the author for obtaining supports is one which in-
volves the grafting into the desired position portions of the septum or turbinates
of the nose, and in certain cases much help is obtained from these transplanta-
tions. Further, mechanical supports through an existing palatal orifice have
been used by the author in syphilitic cases, after providing the other two
necessary elements of the skin and lining membrane.

INJURIES OF THE NOSE

213

The external covering presents fewer features of interest. It may be
obtained from the arm, the cheek, the forehead, or from the chest by the
author's pedicle. See figs. 389 and 390. From these methods the best-looking
nose is undoubtedly that which is made from the forehead skin ; the sebaceous
and greasy nature of the skin, together with its colour, render it more like nasal
skin than that from any other part. Recently, an attempt has been made to
provide the skin covering by a whole-thickness free-graft taken from the inner
side of the arm ; but, although this procedure is not yet completely proven to be
a successful method, it seems certain that it will shortly be an established prin-
ciple. In the author's opinion, an exact pattern of the raw area to be covered
should be made of tin-foil and the flap from the forehead cut exactly to shape.

FIG. 390. Rhinoplasty from chest, author's tube-pedicle method

The tin-foil model is made a little smaller than the raw area in order that the flap
should be on natural tension. One has seen a great number of constructed noses
the fat and clumsy appearance of which is, in my opinion, due to cutting the flap
larger than necessary, to " allow for contraction." One's opinion is that no
contraction can occur if the correct skin lining and supporting structures have
been provided.

The treatment of stenosis of the anterior nares, due to imperfect rhinoplasty,
has been successfully dealt with by means of the Esser epithelial inlay. Many
other types of stenosis are present as a result of gunshot injury. When the
author undertook the problem of complete rhinoplasty, his first ambition was
the production of noses which had an absolutely clear airway. Consequently,
many operations are frequently necessary to clear such airway before the

214 PLASTIC SURGERY

reconstruction is commenced. The principle of sewing skin to mucous membrane
round the margin of an aperture is a very sound one and prevents contraction.
The method of dealing with the restoration by means of a " Vallancey swing,"
has the inestimable advantage of giving such access to the nasal cavity that
the debris of the injury can be successfully removed debris which could not
possibly be attacked through the anterior nares.

ILLUSTRATIVE CASES

The following cases have been arranged into groups according to the site and extent of
the injury :

GROUP I represents the minor injury of loss of the upper quarter of the bridge of the nose.

In GROUP II the upper half of the nasal bridge has been destroyed, producing a type
of nose that one might call the "bird beak."

GROUP III comprises cases where the bony ridge has been broken or destroyed : in these
the tip still remains in fairly normal position, and the bridge is flattened, but there is no
important loss of the lining membrane.

GROUP IV deals with cases where the middle of the nose has been destroyed or crushed,
and is accompanied by tilting of the tip (pug-nose type) and considerable loss of the lining
membrane.

Under GROUP V have been collected the Indian mutilation type, together with various
cases showing loss partial or complete of the structures of the lower third of the nose,
including the tip and ala 1 .

GROUP VI. In this are cases of loss of the lower two-thirds of the nose, i.e. they are
practically cases for complete rhinoplasty save that a small portion of the bony bridge
re-mains.

GROUP VII. Total loss of the nose, and, in some cases, with loss of the bed on which
the nose is built.

Hums of the nose have been described in a separate chapter.

GROUP I

NOSES, SHOWING THE LOSS OF THE UPPER QUARTER OF

THE NASAL BRIDGE

This class of case is simple to treat in a number of ways, and a number
of methods are available.

The two cases illustrated have been treated by one method, the principles
of which are the following :

The skin covering is supplied by advancing flaps from the neighbourhood
usually the glabellar region, the supporting structure is provided by the turn
down of an osteopcriosteal flap from the glabellar region, while the skin lining
is disregarded.

The reason for the latter is that the apertures into the nose arc so small
that they may be frequently obliterated by suture, or, if not amenable to this
treatment, t heir continued existence at such a high point of the nasal cavity does
not lead to infection and uleeration of the supporting structure.

INJURIES OF THE NOSE

215

CASE 30

In addition to the loss of the upper quarter of the nasal bridge, this man had lost his
left eye. The covering was obtained by a straight advancement of the skin over the glabellar
region flap A.

After excision of scar at the bottom of the depression only a small opening into the
nose remained. This was partly obliterated by suture. The small osteoperiosteal flap

FIG. 391. The healed condition.

FIG. 392. Result : note absence of artificial eye.

was turned down and sutured to the back of the existing
bridge.

Details of this operation are appended.

7.7.1G. Operation. A. "U "-shaped flap, with
its base upwards, was dissected off the frontal bone,
and a wedge of this bone turned down reverse side
uppermost so that it met the existing bridge. An
attempt was made to stitch it in this position with
catgut. A portion, however, was broken in the pro-
cess. The frontal skin-flap was brought down to meet
the existing skin of the nose and the wound closed.

13.8.16. Result. A small broken piece of the
frontal graft was exfoliated ; otherwise, normal healing
and the very satisfactory result from a cosmetic point
of view.

Fia. 3 93. Osteoperiosteal flap turned
down from glabella. No skin. lining.

PLASTIC SURGERY

CASE 87

Shows an injury caused by a transverse bullet- wound. The eyes escaped damage.
Tin- only difference in this case was that the flap from the glabellar region was secured by

means of an oblique swinging advance-
ment. Lines of the scar after operation
are shown in the photograph, fig. 395.
The osteoperiosteal flap was turned down
in the same manner as in the previous
case, and the details of the operation are
appended.

1.1.17. Operation.

METHOD OF TREATMENT. 1. Sliding
flap from forehead to provide skin. 2.
Hony support formed by turning down
osteoperiosteal flap from the forehead.

PLASTIC OPERATION. Scar tissue
excised ; large oblique frontal flap turned
up. Two vertical incisions through
periosteum in line with nose. Small
plate of bone chiselled o r f between these
incisions, and bone, with periosteum,
lifted and turned downwards over bridge
and sutured into place. Skin-flaps ap-
proximated over all.

Fir.. :!!)4. Loss of upper quarter of bridge bullet wound.

Fio. 39.1. Shows result. The oblique swinging
frontal flap can be distinguished in its sutured
position.

Fio. 39C>. Kesult. Vartial side view.

INJURIES OF THE NOSE 217

GROUP II

When this loss of the bridge is of a more extensive character, what' one has
called the loss of the upper third or upper half of the nasal bridge the bird-beak
class this method of osteoperiostcal support is not sufficiently firm, and has
not been used.

1 he ideal method for this repair consists of the implantation of the necessary
cartilage in an adjacent skin-flap (the glabclla usually) as the first stage. Sub-
sequently this cartilage and skin-flap are swung down together, and the necessary
covering provided from the forehead. With loss in this situation it is not neces-
sary to divide the repair into two stages, and the cartilage may be imbedded
between the two flaps at the time of operation. lhe author has no case to
illustrate this method. In one of the cases following, the support and lining
were provided by a septal swing, followed by a later implantation of a cartilage
rod. I his gave a sufficiently satisfactory result, lhe skin covering was pro-
vided by advancement flap from the cheeks a bad method as a rule. In the
other case no epithelial lining was provided, and the support was an osteo-
periosteal graft from the tibia, while the skin covering was provided by an
advancement of the skin between the eyebrows, lhe result was a partial
failure, and the method is obsolete because no epithelial lining is provided.

218

PLASTIC SURGERY

CASE 268

In this case the loss of tissue comprised :

1. The nasal bones, underlying portion of septum, frontal spine, and upper portions
of nasal process of superior maxillae.

2. The skin that should cover this part of the nose.

3. The right eye.

There was a small opening into the nose surrounded by scar tissue and granulations,
which, when excised, left a bare area of about ^ in. square.

4.6.16. First operation. Excision of scar, and submucous resection of a piece
of the perpendicular plate of the ethmoid, which was swung forward to form a bridge, and
sutured below to the septum of the lower nose with catgut. Two sliding lateral flaps from
the cheek were cut, undermined, and sutured over this bridge with fine interrupted silk
(vide fig. 399).

Result, Slight breaking down near the angle of the right eye, which socket was not
entirely clean. Primary healing of the rest, with excellent cosmetic results. As antici-
pated, the bridge gradually sank, as the bridge of septal cartilage was not strong enough
to support the contracting skin flaps.

3.9.16. Second operation. Gas and oxygen anaesthesia by Capt. II. E. G. Boyle,
who, on a visit, kindly gave a very satisfactory demonstration of this method.

Small skin incision ; skin very carefully undermined from below upwards until the
frontal bone was reached, when the depth was increased, and the periosteum incised and
raised. A piece of rib cartilage of the necessary length was cut, fashioned, and inserted
under the skin and periosteum, its lower end resting on the cartilage of the lower part of
the septum. Catgut ligatures were inserted to hold it central, but, as the photos taken
two months after show, the lower end slipped off the cartilage and produced a slight de-
formity.

With the fitting of an artificial eye the result was very satisfactory.

Kin. 397. Loss of upper half of bridge.

Fio. 398. Result, two operations. Xote the slipping
of the lower end of the cartilage rod off the septum.
The fixation of a cartilage implant is most important.

INJURIES OF THE NOSE

219

FIG. 399. Diagrams showing incisions, flaps, and suture of first operation. Note the wire retention suture
from cheek to cheek, and the septal advancement as a support. 4.0.10.

FlO. 400. Profile before.

FIG. 401. Profile after plastic and cartilage implant.

220

PLASTIC SURGERY

CASE 125

This was a case of a similar condition. In its repair, both skin-flaps and the supporting
structure were different from the previous case.

In regard to the skin-flaps, the diagrams illustrate their use. The glabclla flap A was
advanced to meet the nose (A 1 ), while two lateral flaps (B and C) were advanced to meet
the sides of A. In order to close the nasal opening, a flap of periosteum only was turned
down beneath A, see fig. 406. Supporting structure was furnished by a bridge of thin osteo-

Fio. 402. Loss of upper half of nose.

FIG. 403. The skin-flaps. A is advanced to A'.\

Flo. 404. Suture.

Fia. 405. Early result. Xote relaxation button.

INJURIES OF THE NOSE

221

periostcal graft from the tibia. It extended from the glabellar region to underneath flap A 1 ,
which was undermined.

The immediate result of this procedure was very satisfactory, but, owing to the failure
of the supporting structure to consolidate, the bridge fell in, and contraction and retraction
occurred.

In addition to the new bridge partly collapsing, the tip of the nose was slightly drawn
up. Most of this failure was determined by the absence of epithelial lining.

This case is published because it shows many interesting features to avoid. A better
method for this particular case would have been as follows :

First stage. Cartilage of necessary length to complete bridge imbedded in glabellar
region.

Second stage. This flap and cartilage turned down, skin surface inwards, and covered
by a transposed frontal flap.

Note. Big, straight advancement from the frontal region, as is evidenced in this case,
does not give a satisfactory result, although the smaller ones on Cases 87 and 30 are quite
satisfactory.

Details of Case 125 are appended.

13.2.17. Plastic Operation. The scar tissue surrounding the sinus into the nasal
cavity was removed. Two incisions were made upwards on to the forehead forming a flap.
Two more on either side were made running outwards on to the face, forming another flap
on each side.

A piece of periosteum was turned down from the frontal bone and the end placed over
sinus.

Another piece of periosteum, with a slight amount of bone attached, about 2 in. by
1 in., was removed from front of right tibia and laid lengthwise, extending from forehead
nearly to tip of nose. Skin-flaps approximated, as in fig. 404.

Flo. 4!)(i. Shows indifferent final result of this method, due to the failure to provide an epithelial lining to the new
portion of nose. Contraction and retraction have occurred. The diagram indicates the construction of the lining,---
periosteum only.

PLASTIC SURGKHY

GROUP III

Depression or destruction of the bridge of the nose without distortion of
the tip or serious loss of the lining membrane. These cases are amenable to a
restoration by implantation of a new cartilaginous bridge.

1 he last of this group really belongs to Group IV, but, as it was treated on
lines laid down as efficient for Group III, it is included here. Ihe indifferent
result obtained in this case is due to the fact that one did not realise that there
was serious loss of the epithelial lining.

CASE 171

The injury to this officer was due to a crash in an overturned motor-bus at the Front.
In addition to the whole bridge of the nose being driven in, he suffered a depressed fracture
of the frontal bone. He was admitted for plastic treatment of the resultant deformity.
A double cartilage implantation was made, one to the bridge of the nose and a smaller
piece in the depression over the frontal bone. This was an early case, and one did not
appreciate the fact at that date that cartilage remains the same size as when implanted.
Allowance was made for some absorption, which, however, did not occur. The profile
restoration was good, except in the neighbourhood of the glabclla. and the general appearance
was markedly improved. There was a slight displacement of the small plate of cartilage
inserted in the depressed fracture of the frontal bone, and the nasal cartilage was a little
too thick and too long. The cartilage for this restoration should be cut to the exact size
necessary, and should be most efficiently anchored into position by catgut sutures or by
tucking it under some periosteal flap. The slight deformity remaining could most efficiently
and easily be cured by simple excision of the redundant portion of cartilage; but the pressure
of war has prevented this officer from having this correction made. It is a mooted point
whether this bridge could not have been raised by sub-mucous division of the nasal supports
combined with a Carter type of bridge elevation. The frontal depression would have
required separate correction. Details of operation are appended :

31.3.17. ()]>i'r(itii>n. Semilunar flap, with convexity downwards, lifted from root
of nose ; small periosteal and bone flap chiselled upwards, creating a notch to serve as
support for graft. Skin over dorsum of nose down to tip separated from underlying tissues
by undercutting, through original incision.

Cartilage graft. .'i in. in length, taken from 7th costo-stcrnal junction in the right thorax,
shaped, and inserted beneath skin and underlying tissues of nose as far as the tip and tucked
in beneath the periosteal flap above.

.Siiuill frontal scar separated from its deep adhesions by undercutting through original
frontal sear, and a small piece of cartilage sutured in position.

INJURIES OF THE NOSE

ON ADMISSION

223

Fid. 407. Full face. FIG. 408. Profile.

AFTER CARTILAGE IMPLANTS

FIG. 409. Full face.

FIG. 410. Profile.

Note : the prominence in the glabellar region can bo
easily dealt with by excision of redundant cartilage.

_".' t

PLASTIC SURGERY

C.'.SK 102

This case shows loss of all the lower portion of the nasal supports, and the interest
of the ease rests in the successful application of dental nasal splints as a preliminary measure.
Had this splint been available a few hours after the receipt of the injury, it is possible that
the restoration by this means might have been even more perfect. It is, however, to be
recognised that there is loss of the external skin and epithelial lining and of the septal sup-
ports. Therefore, no mechanical restoration could have been perfect. A very nice-looking
and satisfactory nose was obtained, as a result of cartilaginous implantation, but it is not
a restoration to the normal, because no provision was made for the accompanying loss of
lining membrane. It is especially to be observed that, despite the satisfactory restoration,
the alie are drawn up on each side and the tip is still somewhat depressed.

In regard to this cartilaginous implantation, it is the first time, as far as the author is
aware, that a piece of cartilage was used down the columella to prop up the bridge cartilage
and the tip. This method of supporting the tip has become almost a standard practice in
the later development of our rhinoplastics. Operation, etc., notes given below :

Restoration of the nose by splint and cartilage graft. . . . Wounded on 20.12.16.
The condition on admission, nine days later, to the Cambridge Hospital, Aldershot, is shown

FIGS. 411 and 412. On admission.

in figs. 411-412; the anterior part of the septum, with portions of both alse. having been
shot away, a considerable flattening of the nose resulted.

15.1.17. /'/;*/ operation 1\\c flattened portions having been freed of all their

adhesions, the apparatus shown in fig. 413 (drawn by Professor H. Tonks), (made by Captain

King and staff) was inserted. '\ his was continuously worn by the patient for seven

weeks and produced a very considerable improvement, as sliown in fig. 414. Figs. H 5-416

later and permanent result of the insertion of a graft 3 in. in length, taken from

the eighth rib. to raise and support the lower part of the nose. The cartilage was inserted

in two Portions through the columella; the longer portion was pushed in beneath the skin

rm the bridge, while a shorter piece was imbedded down the columella towards the

i so as to support the tip of the nose. Plastic re-suture of the ala; to give symmetrical

iranee was carried out at the same operation. To Captain Kclsey Fry, MX'., belongs

t nl giving the nasal splint the prolonged trial, which ended successfully.

INJURIES OF THE NOSE

225

. 413. Retention apparatus for the ncse. It is
fixed to the upper teeth by a metal cap splint.

FIG. 414. Result obtained by operation and the
wearing of the apparatus for seven weeks.

FIGS. 4 15 and 410. Result of plastic opDrations on aloe, and cartilage support to the bridge. Cartilage was
inserted in two portions, one along the bridge and one down the co'.uinella. Date of operation, 9.3.11".

220

PLASTIC SURGERY

CASE 36

This is an example of a definite group of nasal injuries. Those cases coming to one's
attention have been due to high-velocity bullets at short range, traversing the face ap-
proximately from one malar region to the other. Encountering hard bone on the way,
its force is "transmitted to the upper jaw, detaching it from its superior attachment. The
whole support of the nose is also destroyed, and replacement of what remains of the sup-
porting structures is very difficult, unless a case is specially treated for this within a few

davs of injury.

The complete detachment of the superior maxilla is well shown in the photograph, as
is the condition of this officer on arrival. The whole face is lengthened, and, while his lower
jaw is fully open, his upper teeth are in contact with the lower. Ihere is some evidence
of recession of the upper lip owing to loss and displacement of the underlying bone. In
this particular instance an attempt was made to replace the nasal bones by intra-nasal
supports, but completely failed. 1 he treatment of the fracture of the upper jaw was under-
taken by Captain F. E. Sprawson, R.A.M.C., with Kingsley type splints, and the excellent
result is well seen in the shortening of the face (fig. 419). Union has occurred in the upper jaw.
Details. The sniper's bullet entered by the right malar and came out, after fracturing

the maxillae, through the left cheek at the side of the
nose, and the whole of the nose was left very flat and
broad. On his admission, fourteen days after injury,
an immediate effort was made at replacement by
intra-nasal splints, but without appreciable success,
due to the actual loss of bone.

Four months later a plastic operation was per-
formed to raise the line of the bridge by means of
perforated shaped celluloid. The diagram of this
sufficiently illustrates the manoeuvre. It was
moderately successful in appearance, but there con-
tinued to be some slight discharge combined with
protrusion of the celluloid at the tip of the nose, and
it had to be removed after two months. The cellu-
loid plate was J in. thick. After four months, during
which the small scar at the tip of the nose, produced
by the celluloid, was excised under local anesthesia,
the patient was again operated. A thick piece of
rib cartilage, 3 in. in length, was taken from the right
thorax (8th) ; this was grooved on its under surface
so as to obtain greater fixity of position. From a
semi-lunar incision, with its convexity downwards,
at the root of the nose, the skin over the dorsum of
the nose was freely under-cut. The graft was inserted,
and its upper end wedged under a small periosteal

flap of the frontal bone. In order to give more prominence at the middle of the bridge, a
second smaller piece of cartilage was superimposed, while a third quite small piece, through
a separate incision, was used to reinforce the left ala. Slight suppuration followed this
operation, and lateral incisions were made about half-way down the nose. This infective
discharge continued for the best part of three months, i.e. until 26.6.17. Four months
later the condition was fairly satisfactory ; the main graft had not become infected, but had
somewhat moved its position, and, covered by mucous membrane, was plainly palpable at
each nasal orifice. There is deficiency of prominence of the tip, while the left ala has not
been readjusted since the wound. Scars were also present from the previous incisions.

To correct these deformities, the following operation was carried out. A sub-mucous
resection of the cartilage graft through the right narcs was effective in increasing the size
of the nasal passage and in providing a piece of cartilage. This incision into the mucous

Fio. 417. Diagram to represent the im-
plantation of a celluloid support to bridge
and columella. Result : failure.

INJURIES OF THE NOSE

227

Fio. 418. Condition on admission. Double fracture of maxillae with downward displacement.

membrane was carefully sewn up with horsehair. The piece of cartilage obtained was
roughly an inch long. It was shaped and inserted, through a small lateral incision in the
columella, under the tip of the nose to give this more prominence. Small scars were removed,
and the left ala was lengthened and brought more central. All wounds healed by first
intention, and the result was satisfactory. This is probably the first time that a sub-mucous
resection of imbedded cartilage has been carried out and the cartilage reimbedded in
another portion of the nose.

28.11.17. Discharged to duty. Result very satisfactory.

1.4.18. Returned for reconsideration. No further plastic is at present advised.
Still requires a small portion on the tip of the nose. Although the nose in itself is fairly
good it is set too far back on the face, owing to the fracture with loss of the superior maxilla.

FIG. 419. Result of replacement of maxilla; and cartilage implant to nose, etc. The scars on tip and
lateral aspects of nose are due to suppurative troubles.

J-JS

PLASTIC SURGERY

CASE 252

This is another example of complete upper jaw detachment, with destruction of the
nasal supports. The injury was due to a bullet at short range. 1 he entry and exit wounds
are visible in the fig. 422. The terrible deformity is best realised by examination of fig. 4'20.
which portrays his condition before being wounded. The whole of the upper part of the
face seemed to move on a line running from the mid-part of the glabellar region through
the orbit above the bony floor, and through the external angular process to the temporo-
mandibular joint.

The treatment given this case was, first of all, an attempt to manipulate the nose and
upper jaw into position, and the fitting of a Kingsley splint. Two months later it was
found that no union had occurred, and a stronger type Kingsley was applied.

Serious damage had been done to this patient's vision, which became worse when this
stronger splint had been in position for a few days. T he splint was removed and the eyes
examined by Captain Williams, and Mr. Holmes Spicer, of London. An exploratory

operation was advised. Captain A. Ryland, K.A.M.C..
investigated the various sinuses, especially the sphenoi-
dal. Isio pus was encountered, but after a severe epis-
taxis, the vision gradually improved to a certain extent.
To decrease the deformity of the bridge, a combined
bone and cartilage graft from the rib was inserted from
above six months later. The diagrams attached show
the shape of the graft after it had been fashioned. The
bony portion was split and fitted over the freshened
nasal bones like a penthouse, while the attached car-
tilaginous rod extended down to the tip of the nose.
A very marked improvement in profile occurred, but a
twist developed in the car-
tilage, which marred the
effect. This operation is
described because it is an
important eilort to replace
the nasal bridge by its two
elements, bone and car-
tilage. Bony union oc-
curred between the rib and
nasal bones. A piece of
cartilage under the left eye
slipped out of position. No further treatment has been undertaken for this patient.

After consideration of later cases, there is no doubt that this case should have been
treated on the lines of Case 155, which follows, and is a definite failure because no provision
w.-is made for the large amount of epithelial lining which had been shot away, and which
had necessarily to be supplied before the nose could be restored to a normal position.

These three cases, 36, 155, and 252, are all similar, but of increasing severity of loss.
On the one hand, Case 36 was successfully treated by cartilage implantation alone, while
( ;isr 155 had a considerable new amount of skin-lining as well as support provided. , Case 252
was treated on the lines of 36, but should have been treated as was Case 155.

Fia. 420. Before wound.

FIG. 42 1. Bone-cartilage trans-
plant from rib. The bony part
is split and is shown black in the
diagram.

INJURIES OF THE NOSE

229

FIG. 422. On admission. Note downward
displacement of maxillae.

FIG. 423. After replacement of maxillae by
dental splint.

FIG. 424. After bone-cartilage graft. See reading matter re defects in designjand technique which

produced this inferior result.

230 PLASTIC SURGERY

GROUP IV
LOSS OF THE MIDDLE PORTIONS OF THE BRIDGE

Having discussed the transition Case 252, it will have been seen that the
author tried to treat Case 155 at first on the lines of supplying support only.
Fortunately this was a gross failure.

The characters of this group are that there is complete loss of the bony
and cartilaginous support, together with serious loss of the lining membrane.
The tip becomes drawn up and back until the nostrils and columella are so
distorted that the anterior nares, instead of looking downwards, look directly
forwards, or even upwards. " Pug-nose " is the name given to this type of
deformity, and it gives the unfortunate possessors a most repulsive appearance.
Treatment on the lines of distending the skin of the bridge by cartilaginous
or other support is useless because, as has been explained before, it was all-
important to provide the necessary skin lining in addition. It occurred to the
author that the supporting cartilage might be previously imbedded in the flap of
skin to be turned down. A double principle .is involved in this procedure, viz. (1)
provision of the important skin lining ; and (2) the imbedding of the cartilage
in this flap rather than in the external covering flap. Advantages accrue in
that the necessary length of cartilage is easily gauged, and when imbedded
remains in its position ready for inversion or swinging down. Experience has
shown that a cartilage imbedded in the forehead often moves its position or is
bent out of shape. A further advantage lies in the fact that in the process
of hingeing of the flap of skin and cartilage there is a distinct tendency for the
cartilage to spring back. This naturally has the effect of supporting and raising
the extremity of the nose, and the amount of spring can be nicely judged while
the undercutting of this skin-cartilage flap is accomplished. It is a definite
scientific procedure, capable of being pre-judged. The name given to this
flap is the " Vallancey swing," named after the case for which this flap was
first designed and used. As explained in the chapter on Principles, the
author lays claim to this " swing " as a definite new principle on which a number
of plastic procedures are based. To comply with the tenets of this principle
the supports or cartilage must be previously imbedded in the flap that is to be
inturned. The method is applicable to many nose operations where support
and lining arc required, such as are to be found in the following three Groups of
cases, IV, V, and VI; also for plastics of the ala3, of the eyelids, for ear
restorations, and even for the chin. It is further applicable to tracheal repair
and other plastic procedures.

Another new principle of a minor importance was evolved in this case,
and that is the creation of a cartilage store in the subcutaneous tissues.

INJURIES OF THE NOSE 231

Sufficient cartilage for the whole restoration, with a spare piece for accidents,
is taken at the one rib-operation, and the spare piece is inserted under the skin
of the upper abdomen or thorax for future use. It is then available at any
time, and can be easily reached under local anaesthetic. The rib operation is
a distinctly painful one, and avoidance of a second is a great advantage to the
patient. Moreover, if the spare cartilage is not required it can be transferred
to another patient, saving him a rib operation.

ILLUSTRATIVE CASES

The typical pug-nose is shown in the following case, 155. Ihe treatment
of this condition has been standardised as a result of operative procedures in
this case.

The " Vallancey swing " consists of a prior imbedding of a piece of cartilage
of the necessary length in the middle line of skin remaining over the glabella
and upper nasal region. The tip containing the pug-nose alas is definitely
separated from the upper half, and the gap into the nose between the two kept
open until the second stage of the operation.

The cartilage, having been successfully imbedded, is raised with the flap
of skin over it, and swung directly downwards, its lower end acting as the hinge
and blood supply.

Ihe skin over the cartilage thus comes to line the nasal cavity where that
lining is missing, and the end of the cartilage is inserted under the structures
of the tip of the nose which has been brought down to a normal position by
cutting its attachment deeply.

The rod of cartilage thus inserted into the tissues of the tip effectively
prevents the tip from being pulled backwards and upwards. To complete the
operation, a skin covering is usually provided by a frontal flap.

This radical method is absolutely effective and produces uniformly good
results. Great care must be taken that the inverted skin-cartilage flap has
sufficient blood supply. This can usually be secured at the first stage of the
operation, by attaching what is going to be the pedicle of the inverted flap to
the mucosa of the nasal cavity. It occurs sometimes that the blood supply to
this flap is not sufficient to permit complete incision around its lateral attach-
ment ; it is then necessary to leave a pedicle of skin from one or other side of
the nose to be divided later.

When the " pug-nose " retraction is not marked, and is mainly due to scar
tissue, it is not always necessary to insert the cartilage ; but the principle re-
mains the same. See Cases 558 and 598,

PLASTIC SURGERY

CASE 155

Wounded 19. 9. 10.

He was admitted under me on 12.3.17. A mucoccele of the left lachrymal sac had
been operated by the ophthalmic specialist at the Cambridge Hospital, Aldershot, Capt.
Williams, R.A.M.C.

FIGS. 425 and 426. Condition on admission. The Pug-nose deformity.

At this time the author was giving various implanted bodies a thorough trial, and de-
cided, in consultation with one of his colleagues, to insert a perforated sheet-silver bridge of

Flo. 427. Diagram of a paraffin-covered silver support introduced to raise the bridge. Failure.

the form shown in the diagram. This bridge was carefully covered with sterilised paraffin wax
ting point, and, after thorough undercutting of the skin, was imbedded in the

INJURIES OF THE NOSE

233

FIGS. 428 and 429. Show the first stage of the author's principle of nasal reconstruction.

tissues. The immediate cosmetic result was not at all pleasing, and, in addition, the chronic
irritation of the tissues followed by suppuration necessitated its removal.

In the following November, some six months later, the first stage of restoration was
carried out. The operation notes are as follows :

Stage I. Establishment of airway cartilage imbedded. The method selected was

FIG. 430. Illustrates the author's principle of carrying
spare cartilage subcutaneously for later stages. This
saves any further rib operation.

234

PLASTIC SURGERY

FIG. 431. A is the skin-cartilage flap which is swung down to form an epithelial lining to nose,

a support to the bridge, and a prop to prevent the retraction of the tip of the nose.

FIGS. 432 and 433. B is the frontal flap to form the external covering. The lining is formed by the skin of A
now inverted, and the support by the cartilage, which now comes to lie between the two skin-layers.

to imbed a short piece of cartilage in the stump of the nose, and, later, to turn this down
skin surface inwards.

This piece of cartilage was taken from the right costal region and imbedded through
a small incision at the root of the nose. In addition, an aperture was made in the nose
from just above the tip and the edges of the skin tucked in towards the nasal passage. Ad-
ditional cartilage was removed and imbedded in the abdominal wall beneath the skin for
the following reasons :

A. As an extra piece for the nose.

B. As a cartilage prosthesis for the eye.

C. Spare piece.

All wounds healed aseptically.

Stage //.Flap A in the diagram, fig. 431, containing cartilage, was swung down, leaving
the lower portion attached for deep blood supply. The tiny pedicle of skin was also left
on the right lateral aspect for further nourishment. The tip of the nose was now freely
undercut until it could assume a normal position and the extremity of flap A was sutured
to the back of the columella, the cartilage being fitted into the tissues of the tip.

INJURIES OF THE NOSE

235

Necessary sutures were inserted around the margin of
flap A, which completely closed the nasal cavity from
the operative area, except for its tiny pedicle above
mentioned. A model of the raw area now exposed was
made in tin-foil, and a flap of the exact size was cut
from the left temporal region and sutured in position. A
portion of the tip was swung down to give a little more
prominence, and a corresponding addition to the frontal
flap made to cover this extra raw area. A skin-graft
was applied to the extremity of the raw area in the
forehead.

Stage III. Return of pedicle to forehead, and
correction of eyebrow levels. The fistula resulting from
the little pedicle to flap A. stage 2, was excised. Im-
plantation of cartilage to upper part of bridge.

The satisfactory result produced in this case is per-
manent as far as can be judged. There is no change
except for the better (one year after opeatiron).

FIG. 434. Sectional view
of flaps A and B, with the
cartilage lying in between.

Fio. 435. Profile view of result. Compare with
original profile.

FIG. 436. Front view. Artificial eye inserted.

230

PLASTIC SURGERY

CASE 558. Type : loss of the middle third of the bridge of the nose and of the semi-
pug variety.

The interesting points about this rhinoplasty are (1) the absence of cartilage support ;
(2) the method of re-making the left ala to produce symmetry ; and (3) the question whether
it would not have been better to have made the frontal flap larger, so as to have covered all
the external surface. It seems to the author that it should have been brought down to cover
the new portion of the left ala, as at this spot there was some redness of the skin probably
due to the presence of mucous membrane otherwise, compare it with Case 598 (p. 240).

Point 4. When the pedicle was returned to the forehead, a plastic flap of the scalp
was cut, and advanced to fill in the gap. As this man has weak fair hair, the advancement
of the hair-line is of no disability. A further point of interest should be noted, in that the
usual first stage of such an operation was omitted, \iz. the establishment of the airway
and replacement of the parts in their normal positions. The usual first stage also includes
sewing the base of the inturned flap to the mucous membrane to ensure its blood supply,
and in this case, in order to secure the blood supply, a small skin pedicle was left on the
right side. Subsequent to the return of the pedicle a large collection of epithelial debris
had to be evacuated from the right side of the nose.

A bone-graft from the tibia had been inserted into the bridge of the nose prior to the
patient's coming into the author's hands. Various other plastics had apparently been done
before his admission. There was a loss of the inner half of the left ala, and a spicule of the
bone-graft was discovered on top of the nasal bones.

The method of operation consisted of excision of scar tissue and freeing the tip and left
ala, until their normal position was assumed. The skin over the upper part of the bridge
was then reflected downward on its deep base. As the blood supply was insufficient, a
small skin pedicle was left on the right side. When this flap was inverted, it was sewn
to the back of the tip and alse. In order to complete the contour of the left ala a portion
of the tip. marked B l , was swung to the left and sutured to the remains of the left ala (.B 1 ).
To cover the raw area thus produced, a forehead flap of exact size was taken from the left
frontal region and sutured into position. Union was satisfactory, and, despite the fact
that no cartilage was in the inturned flap, there was no tendency for the tip to retract.
The pedicle was returned two months later, and the gap in the forehead was repaired by a

Tip oF nose brought down and
rwintamed by inverted Hap C.
In C was a little ostepfibrtus tissue
the result of a previous tcbal graft

^< ''NV
</ V-."' r)/

437.-B is the frontal flap to cover the defect. Fl o. 438.-The gapjn the forehead is closed by the return

of the pedicle and by a " V Y " advancement of the scalp.

INJURIES OF THE NOSE

237

FIGS. 439 and 440. Pug-nose, combined with ala deficiency.

FIGS. 441 and 442. Soon after the reconstruction. (The lymphatic oedema has not yet subsided.)

k V Y " advancement of the scalp. Some later trouble occurred, due to the tiny pedicle
of the inturned flap of the first operation ; an inclusion epithelial cyst developed on the
side of the nose. It was freely excised, and no further trouble has arisen. The final result
is shown in the photographs. The eyelid plastics are not yet complete.

238

PLASTIC SURGERY

(ASK 495. The disability and the necessary radical nature of the repair were originally
much under-estimated in this case.

It was first thought that by freeing the nose on its right aspect one should be able to
centralise it and then raise it by cartilage graft. An epithelial graft was therefore made
to free the adhesion on the right, and an apparatus to align the nose was worn by the patient
for some time. It certainly straightened the nose to a considerable degree, but it was realised

FIG. 443. Pug-nose, with much lateral loss
and consequent deviation to the right.

FIG. 444. Profile of healed condition.

then how inadequate the procedure was ; moreover, a severe blockage of the nasal airway
persisted.

Therefore this first idea was abandoned, and the case was treated on the usual lines of the
other skin cartilage flaps. A flap of the exact size was cut to fit the raw area of the nose,
and, although this was sufficient for the nose, no allowance was made for loss of skin of the
cheek ; consequently, there is still a slight dragging to the right, although the whole result
is a very satisfactory one. The least support with an extra piece of cartilage would have
rectified this want of alignment, but the patient was so satisfied that he did not wish to have
anything further done.

The tip has been brought down a little too low, but could have been further raised by
the implantation of a columellar rod of cartilage. This procedure definitely established
a good airway through the nasal passages.

The pedicle was not returned to the forehead as the scar-line there was sufficiently
satisfactory ; hence an excision and rearrangement in the glabellar region such as that in-
dicated. The operation details are :

12.4.18. Operation. Epithelial outlay inserted under right aspect of nose and right
ala to allow this to swing forward into position. The bridge to be dealt with later. The
edges of the skin graft, which was cut very thick, were included in the sutures which kept
the stent in position.

2 2. 7. 18. Epithelial outlay successful deviated nose returned to normal alignment.

22.7.18. Operation. Preliminary nasal plastic. Cartilage from eighth right rib
shaped and inserted on the bridge of the nose through incisions between eyebrows. Tip
of nose then released from the remainder of the nose : skin and mucous membrane sewn
together. Nasal passages freely opened, and airway established. The remaining unused
cartilage was imbedded under the skin covering the chest.

Result. Satisfactory healing. Airway established.

INJURIES OF THE NOSE

239

FIGS. 445 and 440. First stage, showing the restoration of the tip to normal FIG. 447. Diagram of second stage operation,

position and tho imbedding of cartilage in the glabellar region.

FIG. 448. Diagram of method of treatment
of the pedicle and advancement of scalp. No
skin graft.

FIG. 449. The result.

22.8.18. Operation. The glabella flap A was swung down with its contained cartilage,
the end of which was inserted into the tissues of the tip to hold the tip down and straight.
The old skin-graft on right side was excised. The edges of flap A sewn to mucous membrane
to complete closure of nose. A flap of the exact size was cut to pattern and the forehead
sewn up. Result : very satisfactory.

14.11.18. Pedicle partly returned and partly excised.

'240

PLASTIC SURGERY

CASE 508

In addition to a major loss of the upper lip and the adjacent portion of the cheek, this
patient suffered destruction of all the lower part of the nose save the columella and left ala.
Some beautifully drawn diagrams by Lieut. D. E. Lindsay, attached A.A.M.C., graphically
describe the methods of repair.

The columella had to be freed and resutured in its, back surface, so as to have no ten-

/Ik

FIGS. 450 and 451. Loss of the lower part of the bridge and right ala. Lip deformity.

dency to retract upwards, and a complete new right ala had to be made in addition to the
top of the nose. For some reason which is not recalled no rod of cartilage was implanted
prior to the restoration, and the flap of skin from the upper remaining portion of the bridge
was swung down and sutured to the back of the tip and left ala. The lining of the right ala
was made by dissecting out a lateral flap from the large deep depression over the right
antrum. This was turned skin inwards and sutured along the lower border of the first
flap. A right frontal flap of exact size and shape was brought down over this raw area.
Xo attempt was made to repair the cheek and lip deformity. It is proposed to insert some
cartilage between the two flaps to give the lower part of the nose a more definite shape.
A very excellent line of union has been obtained between the old and new parts of the nose,
so that in certain areas the line is indistinguishable. An excellent forehead scar was also
produced, and instead of replacing the pedicle it was excised and the eyebrows rearranged.
The right eyebrow is still slightly higher than the left ; but this is more than counter-balanced
by this small frontal scar. The upper lip and cheek repair is a specially shaped flap, which
was considered suitable for this case. Operation details are given below :

22.6.18. Operation. An incision made over the skin of the upper portion of the
nose, as marked on diagram, which enabled flap A to be reflected skin inwards. At the
same time, this incision freed the remains of the columella and left ala so that they could
be brought into normal position.

The extremity of flap A was sewn behind the columella. Flap B, which was a natural

INJURIES OF THE NOSE

241

flap lying inside scar lines, was reflected inwards to line the right ala, and sutured to the
under surface of the tip and along its upper border to flap A. The reflection of flap B was
carried right up to the nasal aperture, so that there was a good curl for the new ala. A
suitable flap, cut to the exact size of the nose, was turned down from the right frontal region.

Fio. 453. Lettering has been omitted on diagrams
Flap A is the upper, and flap B the lower, of the two
flaps. Both are shown after their inversion and suture
to the back of columella.

Fid. 452. Diagram of healed condition.

No attempt was made to extend this flap to take any part in the repair of the cheek. In
regard to the cheek, the deeply depressed scar was excised, and, as a preliminary, a fat-
flap was turned in underneath it and the tissue of the cheek advanced to meet the upper
lip. No attempt made at this operation to correct ectropion of upper lip. Progress very
satisfactory.

FIG. 454. Raw areas after excision of scar
and inturning flaps to line nose.

Fio. 455. Shape of the frontal flap and its suture as
the external covering of the new portions of nose.

_' H'

PLASTIC SURGERY

15.8.18. Operation. Treatment of nose pedicle.

(1) Partial excision of redundant skin. No replacement, as the eyebrow was only
slightly raised and the forehead scar was very good.

(2) Excision of scar tissue above right corner of mouth. The remaining portions of

FIG. 456. The lip incision.

Fio. 457. The lip suture.

the upper lip hereabouts were freed as two small flaps, and sewn together in correct position
to complete vermilion border. To fill the large gap caused by this rectification and the
excision of the scar, a new flap was designed (original) model is attached and sewn into
position with catgut and horsehair. It fitted very snugly into position, owing (1) to being
cut on the curve ; (2) the extra excision of some indifferent skin to allow the pedicle to
twist easily. Secondary closure difficult but satisfactory. Retention sutures used.

Fio. 4. Hap to reconstruct upper lip and cheek FIG. 459.-Suture. This diagram also shows method
nasal reconstruction. of deaUng with the nose pedicle by excision as compared

with replacement.

INJURIES OF THE NOSE

243

FIG. 460. Frontal flap in position.

FIG. 461. Pedicle returned and lip repaired.

FIG. 4C2. Same full face. Note the slight
elevation of the right eyebrow.

L'U

PLASTIC SURGERY

CASE C27

After examination of the first record, one is inclined to regard this case as a minor
injury. In fact, it was not thought that it would be necessary to do more than an excision of
scar combined with a small cosmetic implantation of cartilage. This was an error of diag-
nosis, in that one had not appreciated the amount of loss that had already occurred, and what
was going to occur, in the middle structures of the nose. The left antrum was involved and
most of the bony supports on the left side underwent necrosis. Unfortunately, a photograph
was not taken of the stage immediately prior to operation, but an excellent plaster cast.
by Lieutenant J. W. Edwards, Sculptor to the Department, has preserved a record of this
stage. Comparing this with the photo, it will be seen what a large deformity had super-
vened. A very small " Vallancey swing" was used, and the frontal flap was carried on a
long tube-pedicle, containing a branch of the superficial temporal artery. A most excellent
repair was effected, with invisible scars. A part of the tube was subsequently imbedded
in the cheek beneath the left eye to fill up an existing hollow, and the rest of the pedicle
was returned to the scalp. It should be observed with these long pedicles, having a large
arterial supply, that a sufficient venous return is provided ; otherwise thrombosis is liable
to occur at the extremity of the flap. No fear of this occurred in this instance, as the pedicle
was cut sufficiently wide. The great advantage of this method of bringing down the neces-
sary skin is that it leaves the lower part of the forehead untouched by scars, and the scar
remaining is one running parallel to the natural lines. The operation notes of this case
follow :

16.7.18. Operation. Cartilage from rib removed and inserted over bony bridge of
nose, and spare cartilage imbedded in abdominal wall subcutaneously. Scar tissue now
freely excised. Lower part of nose freed and by careful suture of skin and mucous membrane
retained in its normal position. Similarly, skin was sewn to mucous membrane in upper
margin of the central nasal aperture and airway established. Result satisfactory.

Fid. 403. Cast on which the flaps were
designed. The lining and support were
made by inverted flaps, that over the
bridge ,,, laming a rod of cartilage
The supoHic-ial temporal flap is outlined

^^^^^^^^^^^^^^^^^^^^^B

FIGS. 464 and 465. Condition when suppuration has ceased and skin edges
have been united to mucous membrane around the aperture.

FIG. 466. Cast of the suture. Note Fio. 467. Diagram of the reconstruction. Fio. 468. Shows the tube-pedicle lying

the tubing of the temporal flap. on the cheek.

FIG. 469. Result after return of pedicle. Fia. 470. Side view. Note that part of the pedicle

has been imbedded in the cheek to raise the eye. (This
has been smoothed out by subsequent operation, in-
cluding a small cartilage transplant from the left ear,)

14,10.18. Operation. I. Small flap with its contained cartilage over bridge of nose
cut, undercut, and swung down, skin surface inwards, and sutured to back of tip, extremity
of cartilage extending into the tip. The upper edge of the tip had to be freely excised in
order to arrive at healthy skin.

2. Instead of carrying this flap on the usual pedicle it was carried by a pedicle along
the left temporal artery. When sutured into position the pedicle lay across the cheek
beneath the left eye (see photograph). Pedicle tubed and flap sutured into position. Fore-
head closed by approximation. The upper part of the bridge from which the small flap
had been taken was covered in by approximation over the bridge. Result very satisfactory.

Stage ///.Part pedicle returned to scalp. Part imbedded in cheek local anaesthesia.

PLASTIC SURGERY

GROUP V

LOSSES OF THE ALA AND LOWER THIRD

The seven cases under this group vary from a very minor injury to the tip
and ala to the major loss of the lower third of the nose. Intermediate between
these two extremes lies the type known as the Indian Mutilation. The more
severe cases border on the next, or Group VI, in which is described loss of the
lower two-thirds.

CASE 730

This Case is chosen for illustration for several reasons. In the first place, it is an ex-
ceedingly minor injury, the design for the repair of which gave the author considerable
concern. The rest of the face is absolutely untouched, and one hesitated to make a scar
anywhere. How was. one to provide the skin covering and lining ? After considering the
various possibilities, such as the tubed temporal region flap, and a flap from his arm or neck,
it was decided to attempt a whole-thickness free-graft. On the forehead, these whole-thick-
ness grafts are almost uniformly successful, but in that site the immobility of the surrounding
parts and the excellent blood supply probably determine their success, whereas newly
swung inturned flaps were not considered a very hopeful bed. As will be seen, the graft

Fio. 471. Shows inversion of small skin flaps in
neighbourhood of defect to complete lining and support
for graft.

Fio. 472. The graft sewn into position.

was successful, and a symmetrical tip was produced. There is, however, no prominence
to it as no supporting tissue could be utilised. It is possible, however, that after an interval,
say of a year, cartilage of satisfactory size could be imbedded. Following are details of
the repair :

INJURIES OF THE NOSE

247

FIGS. 473 and 474. Show the effect of thu injury. There is loss of part of the tip and right ala.

FIGS. 475*and 476. Result of Wolfe graft.

17.12.18. Operation. Attempt to make a whole-thickness skin-graft instead of flap.
To form lining of right ala, a flap from the left was swung across and stitched to the skin
of the vestibule on right side. Scar tissue excised and raw area made, symmetrical. A
whole-thickness graft cut from the arm was stitched into place. Graft took in its entirety.

248

PLASTIC SURGERY

CASE 258

An even smaller loss of the tip than the first illustration in this group. This loss was
treated by simple swinging advancements of a whole thickness variety that is to say,
the flap made consisted of skin, cartilage, and mucosa.

This gave a fairly satisfactory result, but is obviously a compromise, and hardly a
reconstruction. An attempt to swing the right ala further forwards and down resulted
in suppuration, which marred the effect. The case was an early one.

Fio. 477. Incisions for advancing flaps.

Details of operation are appended.
Partn; 6 ;^ 01 *" 1 * 1011 f u F reformation of tiP f nose. A thick flap containing skin

"ted t Tn COU f S T m n anC T 5 , CUt accordin g to dia gram, and brought down and
to remains of columella and ales to form new tip

spoilt Vhl' res'ul?^ 1 ' "'" 11116 " ght ^ W&$ lndsed &nd br Ught forward ' Suppuration
right*'? ; * ^ * ^ ^^ ^ ^^ f

INJURIES OF THE NOSE

249

Fid. 478. Partial loss of the tip.

Fio. 479. Result of treatment.

250

PLASTIC SURGERY

CASE 381

An atypical deformity of the tip and left ala. The interest of this case centres in the
use of a caterpillar flap in which a good section of tissue is made to advance in two stages
on its own pedicles. First of all, the lower end is used as a base, and the upper end is ad-
vanced towards the lower. A hump is thereby produced in the middle of the flap. W hen
the upper part, thus moved, has an attachment and a blood supply, the lower part is raised
and the hump straightened out.

Never having executed this manoeuvre before, one was fearful of difficulties of blood
supply, especially in the second stage. However, the first stage proved to be the more
dangerous, while the second stage gave me no cause for alarm.

27.11.17. Operation. A blob of nasal tissue was lying in the middle, which would
make a useful tip if it could be shifted down into position. An attempt to do this was
made in the following manner :

The skin from the dorsum of the nose was incised so as to allow it to shift down cater-
pillar fashion as a first stage. It is hoped that in the second stage, when the caterpillar is
straightened out, the fleshy lump above referred to can be raised and brought into position
for the new tip. The blood supply of this flap was not at all satisfactory, and it had to be
loosely sewn together afterwards. It is doubtful whether the blood supply to the flap
from the new position will be sufficient when the lower mass is detached. The diagrams
represent the first stage of the caterpillar movement.

26.2.18. Operation. The blob above referred to was detached from below and the
back of the caterpillar straightened out. Great care was exercised in separating the two
halves of the middle hump. The blood supply of the flap appeared quite satisfactory, and
the flap made a very satisfactory tip. It was not quite broad enough to fill up the gap on
left side, and, as it was not deemed advisable to put it on tension, this gap was filled by a
whole thickness of skin-graft from the lobule of the right ear. Adjustment of the remains
of the columella and new tip were made.

Progress. The free graft did not take ; otherwise satisfactory.

2.7.18. Operation. Redundant portion of columella excised, and portion of the new
tip swung to left to complete new ala. Result satisfactory.

24.7.18. Excision of small scar left side of nose under 2 per cent, novocaine.

3.9.18. Discharged to duty.

? further treatment any advantage.

i
n
in

-TL

FIG 480. Incision for first stage.

FIG. 481. Suture of the first and second
Below, the caterpillar principle.

INJURIES OF THE NOSE

251

FIGS. 482 and 483. Condition on admission.

FIG. 484. First stage of caterpillar movement.

FIGS. 485 and 486. Besult of this advancement. Note the defect of the left ala.

L'.VJ

PLASTIC SURGERY

CASE 70

The following case is shown as an example of a compromise. The large columella
is detached from below and converted into the left ala, which is missing. This manoeuvre
gives a fairly satisfactory appearance by very easy means. The absence of the columella
is a distinct disadvantage. In this particular patient the rest of the wound was so large
and important that an operation which would quickly obtain a result was indicated. The
case is illustrated because this particular manner of making an ala may be found useful
in other cases. The details of the case and the diagrams of the cheek operations are included
here.

Fio. 487. Detaching columella.

FIG. 488. To make ala.

28 . 11 . 16 . Operation. Removal of sequestrum.

Condition. Large loss of cheek and left ala of nose.

METHOD OF TREATMENT. 1. Lateral sliding and ascending cheek flaps. Successful.
2. Local fat-flaps under depressed scar. Satisfactory. 3. Formation of left ala, by
utilising columella. A satisfactory makeshift.

PLASTIC OPERATION. 27.9.16. Plastic operation on face.

PLASTIC OPERATION. 27.11.16. Second plastic operation. Excision of scar on the
t cheek and occlusion of the gap with local fat-slide, left ala of nose freed and brought
down three-quarters of an inch in the middle line.

PLASTIC OPERATION. 12.1.17. To reinforce left ala. The columella dissected up
>m lip and short flap made. Existing ala freshened and undercut, and columella
turned upon itself and sutured along line of ala. The split base of columella sutured
to form a new one.

INJURIES OF THE NOSE

253

Fra. 489. Condition on admission.

FIG. 490. After cheek plastic.

Fio. 491. Profile view of new ala.

FIG. 492. View from below, showing deficiency
of columella.

254 PLASTIC SURGERY

CASE 10

This case, although an incomplete one, is shown for various special reasons.

In the first place, it is one of two examples of a star-shell burn in our clinic, and re-
presents the effect of a magnesium flare fired from a Verey Light pistol at close range. It
is the more deplorable because of the foolish nature of the accident. The effect would
appear to be due to two causes, one the force with which the projectile penetrated the
face, and the other the burning effect of the magnesium on the inside of the maxilla.
Practically the whole of the interior of the nose was burned away.

The floor of the nose, the septum, the left lateral nasal wall, the left alveolar process,
and the floor of the left antrum were found involved in the destruction. Excessively thick,
non-yielding scar tissue bound the upper to the lower jaw on the left side. The skin lesion is
apparent in the photograph, figure 493, and includes a portion of the upper lip, cheek, left
ala, and a portion of the nose.

This case, the only one the author has treated by the Tagliacotian method, was un-
finished owing to the death of the patient from a severe concurrent disease, and the record
of the case is not as complete as the actual result. The method of forming the ala is of
considerable interest ; a piece of cartilage was taken from the antihelix of the left ear and
inserted in the left arm with the skin tucked underneath it to form an ala. This was trans-
ferred to the nose after suitable interval, the arm being held in place by plaster bandages.

However, considerable suppuration of the flap occurred during this stage, which may
have been caused by frequent contamination with vomitus. Nevertheless, it was success-
fully grafted over the cavity in the face, and the new ala, although not in position, was
obviously a satisfactory one. A subsequent minor operation resulted in its being dove-
tailed and modelled into the nose, giving a still better appearance with a great promise
of an {esthetic result. On the third day following this operation a very severe attack of
erysipelas occurred, followed by a small amount of local gangrene and septic broncho-
pneumonia, from which the patient died in isolation hospital.

There is no doubt that more time should have been allowed to elapse between operations,
but at that time conditions were such that it was rather important to proceed as quickly
as possible with cases, one's judgment notwithstanding.

Fid. 493 -Effect of Verey Light injury. Note small hole externally, with extensive destruction of the, maxilla.

INJURIES OF THE NOSE

255

Fio. 494. The new ala formed on the arm by tucking skin
round a piece of ear cartilage.

Fio. 495. Transference to nose.

Fio. 496. The good shape of the new ala is seen. lt_was subsequently brought into a more central position. See text.

25C

PLASTIC SURGERY

CASE 452

This is a case of a R.A.M.C. (Field Ambulance) orderly who lost the tip of his nose by
a piece of shell. The loss is minor compared with the other cases, and the treatment meted
out seems radical.

The results, however, in the author's opinion, justify the procedure, and give a more
satisfactory appearance than any cheek-flap would have done i.e. the French method.
There are one or two examples of tip, alas, and columella being made by French method
showing excellent results, notably, a case of my colleague, E. Seccombe Hett, F.R.C.S.

\Vhere the loss is one-sided and very small I think this is probably a better operation
than the Indian method, but where the loss is both-sided the frontal flap method appears
to give the best results.

Details are appended :

21.2.18. Operation. Rhinoplasty, tip and part alae of nose.

Method. Indian, plus inverted skin-flap.

Inverted skin-flap A outlined from dorsum of existing nose sewn B to B' and C to C'.

In reflecting flap A, a little bit of cartilage was taken from the septum so as to give
stiffening to the tip and columella. The raw area thus made, represented in diagram 2,
was covered by a shaped flap taken from the right of the forehead and swung into place.
This was cut the exact shape of the raw area as measured by tin-foil. The pedicle was very
long and very narrow. Bridge flap variety. Sutured into place.

Satisfactory appearance. The raw area in the forehead was almost completely closed.

BB' cc' BB'

Fio. 497. Flap A is the inturned flap, of which the points S and C are sutured at B' C'.

Progress Satisfactory, except slight haemorrhage from bridge portion of pedicle.
; ^?;7*!;? ntal fla P cut thin ' including only part of Frontalis muscle.
6.3.18. Operation. Return of pedicle. Osteotomy nasal bones.
Result. Satisfactory.

25.C.18. Operation. To rectify columella, which showed a perforation or window on
1 view Local anaesthetic. A small flap on each side was brought forward from
the remains of the septum and sutured to the existing columella
Result. Satisfactory.

INJURIES OF THE NOSE

257

FIGS. 498 and 499. Indian mutilation type. The healed condition.

Fio. 500. Shows the frontal flap with its
pedicle lying over the glabella.

FIGS. 501, 502, and 503. Result after return of pedicle.

258 PLASTIC' SURGERY

INJURY OF THE LOWER THIRD OF THE NOSE TREATED BY A METHOD

OF THE AUTHOR'S

Four cases of injury of the lower third of the nose have been treated on a
new principle. Case 145 which has just to be described was a failure, but the
other three have all been very useful restorations. The principle of the opera-
tion is exceedingly difficult to explain. It is suitable only for losses of the
lower third involving tip and one ala. It is not suitable if the other ala has
been destroyed. First, the distance from the existing nasal bridge to the ideal
tip is measured and a piece of cartilage of that length and of proper diameter
taken. Commencing half-way up the forehead in the middle line, an incision
is carried down through the skin on the less damaged side of the nose, which
incision is stopped at the lower border of the nasal bones. A similar incision
is made on the opposite side starting from the same point, and this V-shaped
flap reflected. Underneath this is inserted the piece of cartilage, which is pushed
down to the base of this flap. The flap is swung back into position and the
first stage is complete. The second stage, after three or four weeks, consists
of the raising of the same flap through the same incision, but in the flap is included
the previously imbedded cartilage. The incision on the sound side is now
deepened, and as the knife leaves the border of the bony bridge it is carried
through all thicknesses into the nasal cavity and continued down close to the
septum. On the side of the loss, the incision is carried down, gradually getting
wider until it extends outwards and downwards into the check. By carrying
the knife beneath the cartilage, it is undercut until the lower border of the bony
bridge is reached. Here it is turned directly downwards into the nose, and all
tissues are cut through, including the septum. The whole flap now consists of the
remains of the columella, the affected ala, the long skin-flap, and the cartilage,
together with a small portion of the anterior part of the septum. Its blood
supply comes through the columella and septum, and through the lateral pedicle
on the affected side. It is freely movable, and the lower extremity of the
imbedded cartilage, with the skin over it, is made in the position of the new tip.
The upper end of the cartilage now slips off the bony bridge and is abutted on
its lower aspect. Similarly, the mutilated ala comes to lie in a position of a true
ala, skin suture is effected in this new position while the sound ala is sutured
to the new tip.

In reviewing this method it is obvious that there is a certain amount of raw
area beneath the cartilage at its upper end and beneath the flap just above
the new ala. More by luck than by judgment, the cartilage has not become
infected nor is the new ala seriously contracted in my cases, and the raw areas
have Ix-romr epithelialised. It is quite feasible, should one be doing this opera-
tion again, to provide the necessary lining for these raw areas.

INJURIES OF THE NOSE

259

CASE 111

This was the second case of total rhinoplasty attempted. This terrible injury in-
volved destruction of the entire nose, the middle half of the upper lip, the pre-maxilla,
and the lateral nasal processes of the superior maxilla. There was also considerable loss
of the soft tissue of the cheeks.

When he had sufficiently recovered from his wound, the upper lip was remade by descend-

A. Periosteum.
B . Rib cartilage.
C . Skin flap..

The periosteum wa,s put round the cartilo-ge
and wa.s sutured below.

Fia. 505. View of the forehead from above.

Fio. 504. The healed condition after the palate
remains had been returned by dental appliance.

ing lateral flaps, the mucous membrane being advanced to complete the red border. This
was moderately successful, but there was an ugly droop at each corner of the mouth.

The next stage was performed some three months later, on 17.4.17, and included the
imbedding of a cartilage rod beneath the periosteum of the frontal region. The periosteum
was made partially to surround the cartilage.

There was some slight suppuration following this graft, about the fourteenth day
after the operation, and a small incision near its extremity had to be made. The condition
rapidly cleared up, but the cartilage and new nose were not brought down on to the
face until some five months later. When the flap was outlined and raised from the
forehead, it was found that the cartilage that had been there so long had made a bed for
itself by pressure atrophy, and force had to be used to raise it from its bed. A large
portion of the under surface of the cartilage, especially near the attached end of the flap,
would therefore have been exposed to the nasal cavity, if one had not turned down the

2GO

PLASTIC SURGERY

FlO. 506. Shows result of lip operation and the
cartilage imbedded in the frontal flap.

FIG. 507. Diagram of the rhinoplasty. Note : the
little flap D was all that was provided in the way of
epithelial lining. Hence the indifferent result.

small skin-flap, marked D in the diagram, to cover this portion. (It is interesting to
note that at this stage the author had not fully realised the significance of the skin-lining
to the new nose, and was labouring under the delusion that a periosteal layer between the
cartilage and the nasal cavity was an adequate protection from sepsis.) This patient had
a very narrow forehead, and, in avoiding the hair-line, the flap was not cut big enough.
It should be noted that an extra large flap was necessary in order to cover in the cheek
defect as well.

Considerable difficulty was experienced in fitting this nose into position, and the im-
mediate result was only moderately satisfactory.

In order to imitate the natural prominence of the pre-maxilla, the tissues of the cheek
were incised, at points A'. Relaxation sutures held these two flaps together, and this
manoeuvre deepened the upper lip. Relaxation sutures were also passed from one cheek
to the other, underneath the new nose.

A slight intra-nasal discharge followed this operation, but it cleared up with syringing.

The pedicle was returned on 4 . 10 . 17, and into the base of the nose a small homologous
cartilage graft was superimposed on the previous cartilage. Over the undisturbed granu-
lations in the forehead a large Thiersch-graft was laid, and bound firmly into position by a
covering of paraffin wax (No. 7), gauze and bandages.

The after-history of this case is unsatisfactory except as regards the skin-graft, which
healed perfectly. The homologous cartilage did not take, and infected the imbedded
cartilage. Six months later all the cartilage appeared to have been absorbed, which disaster
is due to its becoming exposed to the nasal cavity on its under surface.

This case is described in order to point out various mistakes of which one has become
cognisant after the events. It is a mistake to put the cartilage under the periosteum.
It is a greater mistake not to line the new nose with some form of epithelium. The homo-
logous secondary cartilage graft was an injudicious procedure.

INJURIES OF THE NOSE

2G1

FIG. 508. Two days after the rhinoplasty. The
author does not now use rubber tubes.

FIG. 509. After this stage the pedicle was
returned and the forehead successfully grafted.
The nose, however, owing to the lack of epi-
thelial lining mentioned in the text, underwent
considerable diminution in size.

This case is also of interest in that it shows the difficulty of making the nose on an
abnormal bed. Had the nose been a good one, it would still have been set quite 1 in. too
far back, owing to the loss of the pre-maxilla, which loss was not greatly overcome by the
flap manoeuvre carried out at the total rhinoplasty. It would have been better had one
adopted the suggestion of Captain Fry, our chief Dental Surgeon, of separating the new lip
from the maxilla and inserting a dental plate prior to the operation for the nose. This
can, of course, still be done, and by methods that are described in later cases it is yet possible
to procure a satisfactory surgical result.

Another case done by my late colleague, Captain Aymard, at the Cambridge Hospital,
Aldershot, should be recorded, as it is an evidence of an effort at perfection in rhinoplasty
marred by the want of a skin lining.

It was a case similar to the one just described, but it lacked the lateral loss which
complicated Case 111 ; that is to say, the bed on which to put the nose was normal. Captain
Aymard, with the assistance of the sculptor. Lieutenant Edwards, made a model of the
ideal nose in plasticine, and then reduced this by the thickness of a forehead flap. The
remains of the mould were then cut into sections, and cartilage to correspond with this
undcrmould of the nose was cut from the costal region.

In order to get the exact shape more than one piece had to be used. These were
stitched together with catgut. This composite block of cartilage was then inserted between
the skin and aponeurosis of the frontal flap. The appearance for some weeks was remark-
ably good, but, owing to the lack of epithelium on its under-surt'ace, slow ulceration of the
cartilage occurred, with subsequent flattening and contraction of the new nose.

PLASTIC SURGERY

CASE 145

This is interesting as an attempt to perform the author's modified operation. It
partially failed, hut the imbedded cartilage was of service later in the case, when a modified
Keegan-Smith operation was carried out.

The modified operation was different in this case from any of the three next
described, Nos. 140, '298, and 300, in that the pedicle was bilateral, whilst in each of the
other three cases the pedicle was unilateral.

The reason for this difference is that this Case 145 has its anterior nares on the same
level each side, whilst in each of the other cases one was at a higher level than the other.
In comparing his result with the others, one notes objectionable features in the use of double
pedicles.

The result was fairly satisfactory. The lengthening of the nose is seen in photo

(fig. 513). The imbedded car-
tilage is fairly evident. An
attempted columclla from the
upper lip at the same time
broke down.

Photos of the result of
this operation were taken a
year after, and it then had to
be decided whether a corrective
operation to complete the
rhinoplasty on its existing
basis should be performed or
whether the method should be
altered. The latter course was
adopted, and the condition
was now really only one of the
Indian mutilation type.

The turned-down skin-flap
to line the new tip and ala?
was made to contain a portion
of the cartilage of the previous
operation.

The turned-down flap was
partially split so as to get the
Smith variety of the Kcegan
operation.

The exciting part of this operation was the frontal flap, because, as the diagrams show,
the scar of the first operation ran very nearly across the pedicle of the frontal flap. Not-
withstanding this, the blood supply was quite satisfactory, and the procedure appears to
be justified.

This particular patient has a very poor resistance to infection, and at the return-pedicle
operation a considerable sepsis of the forehead wound occurred. A skin-graft to make
good the area denuded of epithelium failed to take.

It will be interesting to note that several plastic operations had been attempted on
this patient prior to his admission to our clinic. Twice he has had his arm tied to his head
and an Italian operation attempted. Both failed.

Fio. 510. Incisions for the rhinoplasty.

INJURIES OF THE NOSE

263

FIGS. 51 1 and_512. The injury. Loss of the lower halt of nose.

FIG. 513. Indifferent result of
special method (used in the
next three cases described).

FIGS. 514, 515, and 510. Result of making new|tip and alaj by double epithelial flaps and cartilage.

See diagram and text.

264

PLASTIC SURGERY

CASE 140

Thr tvpe case is No. 140. Loss of the tip commencing just below the bony bridge
and extending down to the base of the columdla. More of the Iclt ala reg.on was lost
than on the right. Bv an incision which is shown in the diagram a sk.n-flap was turned
down from the forehead. The incision was made on the right lateral aspect ol the nose
from the junction of the ala to remains of septum, up to the inner margin of the right eye-
brow, and then to a point in the middle line of the forehead, about 2m. above the root
,,f the nose. The skin was undermined and raised off the bridge of the nose and a flap
of periosteum 2 in. long by 1 in. broad was reflected downwards from the forehead, being
left attached in the glabellar region.

This periosteum, therefore, came to lie underneath the raised flap of skin and

the existing nasal bridge. , .

A piece of cartilage about If in. in length was now taken, and wrapped in this peric
teum. The skin-flap was placed over this imbedded cartilage.

FIG. 517. Stage 1. The incision for the insertion
of the cartilage.

FIG. 518. Stage 2. The same incision extended
so that the advancement can be made.

Some two months later the second stage was performed. It consisted of an incision
along the right side of the nose in the same line as in the previous operation. At its lower
end the knife was carried deep into the nasal cavity. A corresponding incision was made
on the left side, commencing from the mid-point of the forehead and descending along the
line of junction between nose and cheek down as far as the commencement of the naso-
labial fold. This flap of skin was then raised, commencing from above. At the point
where the cartilage was met the knife was carried deep, so as to raise it imbedded in the
skin-flap. At the point where the existing bony bridge ended the knife was carried
deeply into the nasal cavity. The blood supply to this flap, thus detached, came from
tlie whole thickness of the left ala and columclla.

The whole flap and cartilage could now be advanced downwards, the cartilage producing
a satisfactory support to the new tip. The upper end of the cartilage graft was inserted,
partly under and partly over, the nasal bones by splitting its upper end. The left nasal
opening now formed a satisfactory new left ala, and was brought by this manoeuvre to the
same level as the right one.

The only difficulty in suture occurred at the' re-entrant angle on the left side between
the eye and the nose. A small flap from the left upper lid was turned down to complete
the closure.

Secondary corrections of the tip were performed later with satisfactory result.

INJURIES OF THE NOSE

265

In criticising this method, as evidenced by this particular case, its defects would appear
to be that the tip, in this method of swinging it down, becomes somewhat depressed. It
gave a by no means displeasing effect to this particular patient.

FIG. 519. The healed stage.

Fio. 520. Profile.

FIG. 521. Result of the advancement.

Fio. 522. Profile.

266

PLASTIC SURGERY

CASE 298

The next case, No. 298, was of the same type, but of a very much smaller degree, and
on this occasion one tried to get over the difficulties above-mentioned Avith Case 140 by de-
signing the flaps differently. The skin was advanced from the cheeks and not from the
forehead. The disadvantage of this method became apparent later, as there were two
scar-lines running across the middle line of the new nose, whereas, with the long pointed
flap, the skin was not so marred.

An effort to improve the tip was also made, and a shaped piece of cartilage (fig. 524)
was inserted through a right lateral incision, well shown in the photograph (fig. 527).

Here, again, the left ala was situated at a higher level than the right, and the imbedded
cartilage was swung down with its blood supply from the columella and left ala (flap X in
diagram).

The right ala was sewn to the nose-tip, and the area of skin along the bridge of the
nose caused by the descent of flap X was made good by a lateral advancement flap A
from the right cheek and a long relaxation cut B C on the left cheek. The early result

FIG. 523. Cartilage was imbedded under X. X is then advanced with its
cartilage. The gap is made good by lateral advancement of flap A.

FIG. 524. Shape of the cartilage
inserted.

of this nose was not good from a cosmetic point of view, and the tip could not be brought
down sufficiently owing to a lack of sufficient stalk to the cartilage with which to gain its
purchase from the existing septal bridge. The tip has a tendency to be blue.

Eight months later the condition was very much improved, and a following corrective
operation was performed.

1. Excision of the redundancy of the columella, the cartilage in this columella being
removed and inserted in the depression in the nasal bridge. The tip, which was too fat,
especially on the right side, was reduced by excision of a piece of cartilage from this aspect.

In order to produce a roundness of the tip this piece of cartilage was there inserted.

The result of this corrective operation was very satisfactory, but the slight tendency
to blucness in the tip has temporarily reoccurred.

All scars are rapidly becoming invisible.

INJURIES OF THE NOSE

267.

FIGS. 525 and 526. Loss of the tip and part alae.

FIG. 527. Stage 1 : Implanta-
tion of cartilage.

FIGS. 528, 52'J, and 530. Result after advancement of skin and cartilage. Note : the nose was still becoming

thinner and more shapely when last seen.

268 PLASTIC SURGERY

CASE 300

The third of this scries was of a typical Indian mutilation type, but the left ala
was again at a higher level than the right. The diagram shows the incision of the first
stage at which the cartilage was imbedded. A separate piece of cartilage was imbedded
in the left ala to fill this out. The pcriostcal bed from the frontal bone was similarly turned
down underneath the cartilage. (Diagram 531.)

At the second stage, performed four months later 19.10.17 a flap to the extent and

shape shown in the diagram
was raised with the carti-
lage and slid down to form
a tip. A small prolonga-
tion over the left eye
brought over the frontal
flap not in diagram was

^u v\V'\\ made in order to overcome

J WM--- N '~* thc difficulty of the rc-

// OT%T Periosteum entrant angle when the

H~8Wn advancement had taken

H- Cartilage . T .

place. It was satisfactory
in filling the gap, but was
lost through failure of blood
supply.

The immediate result
was good, but there were
slight irregularities, due to
the failure of the small flap
to live.

All these three cases have shown good results, but each one has shown
certain difficulties of a minor character which have not been solved. The
operation has the very great advantage of producing no large or marked scars
anywhere, and those that are made are in the lateral aspect of the nose and in
the midline of the forehead.

In view of the series of cases done by the Indian method it would seem
that this operation, if capable of further improvement, would supersede the
Indian method for certain types of minor loss of the tip and alee.

One disadvantage not previously noted in regard to this operation is, that
the new tip tends to be cold and a little blue, due to the fact that the mutilated
tip, when healed, has a considerable amount of scar tissue over it. Time has
largely rectified this in my cases.

The author has used this method only on one other case (Case No. 145, q.v.),
but on this type the operation is contra-indicated, as the loss is too severe, and
bilateral.

The later examination showed a quite satisfactory result, except that the left ala was

somewhat retracted, causing stenosis. Ihe columella also was not central or suflicieiitly

Cartilage from the antihclix of the left ear was imbedded to strengthen the

t ala ; at the same time scar tissue was excised and skin tucked in to make a better vesti-

The columcllar attachment was divided above and re-sewn in a more central and

INJURIES OF THE NOSE

269

permanent position. The final result was good, almost as good as if a successful inturned
and frontal flap had been made in the first instance, and there was, in addition, the great
advantage of a minimal secondary deformity. .

Fios. 532 and 533. Loss of tip and part ala\ All the free edge of the left ala is destroyed.

FIGS. 534, 535, and 53fi. Result of advancement operation and minor corrections. (Author's method.)

270

PLASTIC SURGERY

CASE 583

This is really a transition case from our previous group, and there is hardly more than
half of the nose gone ; in addition, he has the enormously valuable remains of the akc.
There is only one feature about the case which is different from the type of operation, and
that is in relation to the external flap, which was cut and arranged differently, by a new
method, around the tip and al;e. There is really very little else to discuss about this case,
and the good early result is only that which is to be expected. The external flap was cut
differently for the following reasons: (1) One has realised for a long time that it is un-
reasonable to expect to be able to make a perfectly fitting covering for the nose out of one
flap a tailor's cutter, if he were asked to clothe a nose, would not make his suit out of
one piece of cloth ; there would be some accessory pieces for the delicate curves of the
nostrils and vestibule. With this idea, the author decided to make the columella and lobule
out of two lateral flaps brought together and sutured down the middle. Situated laterally
to these flaps two further pieces were cut, one on each side, which were curled in upon
themselves and were to represent the portion of the ala? that had to be made. One feels that
a new principle underlies this new method. Something similar was successfully attempted
in Case '203, where an excellent tip was also produced, and it is probable that a modification
of the frontal flap on some lines similar to these two cases will eventually be made. Another
frontal flap similar to that of Case 583 has been made, but the case K in too early a stage
to be sure of the final result. Operation details are appended here :

18.7.18. Operation. Preliminary intranasal work with implantation of cartilage.
Cartilage from 7th and 8th costal cartilage. Skin incision extending from inner side of each
eyebrow downwards to just above the ala on either side.

Skin undermined and cartilage implanted. The incision was made in this way so that
the flap developed its own blood supply. The right ala was separated by a curved incision
running through the alar furrow, and the skin and mucous membrane sutured together.

FIQ. 537. Loss of lower half of nose. Nasal stenosis.

Fia. 538. Profile on admission.

INJURIES OF THE NOSE

271

The same procedure for left ala. Incisions were carried upwards on either side of the septum.
A small V-shaped portion of the septum was excised in its lower portion, and the skin
was sutured to mucous membrane. Tube covered with vaseline gauze was replaced in each
nostril.

Note. Great difficulty was experienced in sewing the skin over the cartilage, es-
pecially on right aspect. A small portion of cartilage remained exposed. Kesult : very
satisfactory. The exposed cartilage was not infected, and was rapidly covered by epithelium.
Nasal airway established.

Fio. 539. Result of the important first stage. (1) Also replaced j (2) airway established ; (3) cartilage
imbedded over glabella and bridge of nose.

17.10.18. Operation. (2nd Stage.)

1. Glabella flap swung down with its contained cartilage.

2. The exposed portion of the septum was incised from above downwards, thus making
a slice which served as a support for the columella. Its back surface was covered by the
tip of the turncd-in glabella flap. The alse remains were freshened and partly sutured to
this same flap.

A bifid frontal flap of special design was brought down from right forehead.

The points are :

The lobule and columella were made by bringing two lateral flaps together while two
further lateral flaps were turned in on themselves to complete the remaining portion of
the ala?. The tips of these inturned flaps were sutured to the original glabella flap.

The antero-latcral aspect of the columella was denuded of epithelium to receive the
above-mentioned columella flaps.

Result. On the table looked very satisfactory. No attempt made to close or graft
forehead wound. Later : satisfactory, but the inturned flaps to complete the ala? broke
away a little, which somewhat spoilt the line of the new ala;.

18.1.19. Operation. Pedicle returned to forehead. Scar tissue excised, and a whole
thickness skin-graft applied to remaining raw area on forehead to readjust hair-line.

272

PLASTIC SURGERY

FiO. 540. Cast taken after first operation, showing incisions for (1) inturned skin-cartilage flap ;

(2) special bifid frontal flap.

I'm. .11 1. 1. The skin cartilage llii| 1 1ms brcn in tun in I.

I h. i-il^o; of nl;i' iiiul columella freshened. :!. The

liilid frontal flop is about to be sutured into place.

Note the formation of tip and columella by the two

- a.

FIO. 542. Suture of the frontal (lap. Note the
inturnrd portion at A and D to complete vestibular
rpil lirliuin.

Note. The suture line of the forehead is incorrect.
See text.

INJURIES OF THE NOSE

273

FIGS. 543 and 544. Profile views soon after return pedicle operation. The Wolfe graft to the forehead

has not yet healed round its edges.

FIGS. 545 and 5lG Early finals.

274

PLASTIC SURGERY

CASE 183

This patient entered the clinic with a sub-total loss of the nose. The upper portion
of the bony bridge remained, whereas the lower part was a mass of skin and cartilage, the
debris of previous plastic operations. There was also a " mucous membrane columclla,"
the redness of which completed the unpleasantness of the effect. Marked nasal obstruc-
tion was present.

It was decided to swing down a flap of skin which contained cartilage, to form the
lining of the nasal tip and vestibules, at the same time to cut away the mucous membrane
columella and to re-establish the airway. This operation was performed on 14.2.18.
It may be divided into three stages : (1) The mucous membrane columella was excised ;
(2) the triangular flap was cut from the existing nose and swung downwards, skin surface
inwards. The extremity of this flap, which formed the back of the columella, was stitched
to a raw area on the upper lip made for its reception. In order to give support to the new
tip, the cartilage that had previously been imbedded was sectioned from above downwards,
until its extremity could be stitched to the raw surface of the first flap in the situation of
the tip. A portion of the cartilage was also left down the columella. There was a natural
tendency for the cartilage to spring upwards. (3) Ihe whole raw area was covered by a
forehead flap carried on a small pedicle, the exact size of which is seen in the appended
diagram. The forehead was closed by approximation, a circular silver wire suture being

used. Healing was exceptionally good, and save
for a breaking away of the upper lip from the new
columella which was probably due to the spring
of the cartilage no untoward result occurred. The
pedicle was returned four months later and the
columella reattached to the upper lip.

Further adjustments, under local aiuesthesia,
were made on two later occasions, and a small
piece of cartilage, from another case, was inserted
through the columella to give more prominence to
the tip.

The patient was discharged on 21.1.19, the
nose looking very natural and having a good
airway. On cold days, or when exposed in a car,
this nose gets blue at the tip, but not more so than
a great number of natural noses. The suture line
between the new nose and side of the cheek is
almost imperceptible; entirely on the left, and
nearly so on the right.

The history of this case teaches a lesson.
Originally there was total destruction of all the
supports except that of the upper part of the
bridge, and the remaining skin of the nose was
lying flat in front of the nasal aperture. Several
attempts at cartilage implantations and small
cheek-flaps had been made with indifferent results
prior to one's taking over the case. In addition, a
mucous membrane columella had been brought
from the upper lip in the region of the nasal
spine.

In view of our later methods, all this diflicult work that had been performed was on
entirely wrong lines. The addition of the pouting mucous membrane columella had not
OTlly a horrible appearance, hut also seriously blocked the airway.

Fio. 547. Composite cast showing incisions
for rhinoplasty and the excision of the mucous
membrane columella that had been made prior
to admission.

INJURIES OF THE NOSE

FIGS. 548, 549, and 550. Condition on admission. Cartilage had been implanted in the nose to raise the
bridge without satisfactory result. A columella had been made out of lip mucous membrane.

FiQ3. 551, 552, and 53;i. -Pictures of tho rosult. Tho pedicle in"jthis case was returned to the forehead, the
balance of the raw area of which was closed by approximation and healed scar.

276

PLASTIC SURGERY
CASE 385

This case is interesting in that it is a stepping-stone to much of the present-day rhino-

plasty.

Previous to this, one designed the " Vallancey swing " (for the pug-nose type) without

quite realising its significance.

This was the first considerable loss of the nose repaired in our clinic by shaping inturned
flaps, and the support was provided by a removable mechanical appliance resting in an
epithelial cavity, while the outside covering was of the usual type. This apparatus was
designed by the late Captain Robertson and is illustrated.

In reviewing this case, one is sure that a better result would have been obtained had
cartilage been provided in the inturned flap and for the alae. In our experience, any form
of intranasal support is liable to produce chronic irritation and stenosis. These two fleshy
flaps making the nose gradually took up a position shown in fig. 560, which is considerably

lower than immediately after the operation. In addition,
epithelial grafts had to be applied to the anterior nares to
give stability to the airway.

The patient is quite satisfied with the result, and it is
certainly an interesting case so far as the later develop-
ment of rhinoplasty is concerned. One year after the
restoration, the junction of the new nose and cheek is
almost invisible, and the colour of the nose is so natural
that its deficiencies in form are greatly minimised. It
should be noted that a very narrow pedicle was employed
for the frontal flap. Secondary deformity of forehead
whence the flap was taken is minimal, while the airway is
sufficient without being free.

25.9.17. Operation. For establishing nasal passage.
26.10.17. Nasal splint, with tubes, fitted.
9.11.17. Previous operations unsatisfactory. Nasal
stenosis present. Operation for cure.

1. Circular incision in a free manner round nasal
aperture.

2. Impression of aperture taken in dental wax.

3. The grafts were then laid over the parts which were
in contact with the raw surfaces.

4. The mould and grafts were then placed into position
and held there by strapping.

5. Two airways were made through the model.
Result. Perfect epithelialisation, except in the floor of

the left nasal passage. A very good quality of skin was
produced on right side. Slight stenosis of left passage re-
mains. General result satisfactory.

Note. This method is an adaptation of the inlay, and
might be called a semi-open epithelial method. Note
the disadvantage on the floor of the nose, owing to
secretions collecting at that spot.

30.1.18. Operation. Rhinoplasty. Sub-total, 1st stage. (Oil ether.)
Reformation of lower two-thirds of the nose by means of double epithelial flaps sup-
ported by temporary vulcanised splint (splint made beforehand, and accurately fitted the
floor of the nose). The skin of existing portion of nose was turned down at a flap A, B,
A, on a hinge represented in diagram by dotted line, which, in reality, was the margin of
the existing nasal aperture.

This flap, when turned down over the splint, formed the skin lining for the new nose,

Fio. 554. Vulcanite intranasal
support in three pieces, over which
the double epithelial flaps were
moulded. This apparatus was
made by the late Captain E. G.
Robertson, attached R.A.M.C.

INJURIES OF THE NOSE

277

including the ala and the back of the columella. Portion of the lip skin A was turned
upwards to meet B and to complete the posterior lining of the columella. A model of
the raw area in stent was then made and outlined on the forehead. The flap was cut and
swung down into place, completely covering all raw area.

It will be noticed that the extremity of the frontal flap was sutured into the upper lip.

The total appearance was very satisfactory. Healing by first intention, and exception-

Fio. 555. Diagram of the inturned flap B and of the forehead flap. The hinge on which B was turned

over is indicated by a dotted line.

ally good scars obtained on the lateral nasal aspect. Stitches removed third and fourth
days.

The pedicle was a bridge pedicle. Treatment of central frontal gap by silver wire
suture. No skin graft.

12.2.18. Operation. 2nd stage.

Bridge pedicle, separated from grafted portion, returned to forehead. A cut was made
into this pedicle to elongate it. The cut nasal end of pedicle was imbedded into the nose.

278

PLASTIC SURGERY

FIG. 556. The injury on admission.

FIG. 557. Profile.

Fio._558. After establishment of nasal airway by excision of scar and Thiersch graft.

INJURIES OF THE NOSE

279

FIG. 559. Result. Pedicle returned to forehead.

FIG. 500. Profile. Note : no cartilage support was used in this case, which would
undoubtedly have improved its lines.

PLASTIC SURGERY

CASE 632

This gunner lost the lower two-thirds of his nose by gunshot on 15.1.18, and was
admitted three months later to the clinic.

There was almost complete stenosis from scar tissue, and the first necessity was to
establish a breathing passage. This was kindly undertaken by Major Justin M. Waugh,
M.R.C. (U.S.). On the left side some remains of the vestibule could be utilised in the
repair. Shortly after that Major Waugh was called to other fields of activity, and one
established the airway on the left side on the visual lines, having given up the idea of using
these small remains of vestibule. At the same time, cartilage was imbedded into the pro-
jected " turned-in" flap. A further thin rod of cartilage was implanted in the left cheek,
which was a new method of making the ala. The idea was that a combined skin and
cartilage flap should be turned in as a lining to the vestibule and a support to the ala. It
is the same principle as the Vallancey Swing. The natural spring of the cartilage should
prevent any atresia of the nares. A most satisfactory ala was thereby secured. A special
design of the frontal flap was made in this restoration. The tip-columella portion of it.
was cut considerably longer than necessary, and when brought into position on the new
nose this redundancy was dealt with by making the flap curl back upon itself over the tip.
Stitches were put in laterally to maintain this fold. It gives a bizarre appearance at the
time of operation, appearing like a square projection at the end of the nose ; but one felt
sure that this would round itself off. As the photographs show, a most excellent tip was
the result.

This case, No. 583, and another case not illustrated, all show definite attempts to
produce a new and better kind of lobule. Details of operations follow :

29.6.18. Operation. Establishment of nasal airway. Result is satisfactory on right
side. Healed well.

10 . 8 . 18 . Operation. (1) Cartilage imbedded into root of nose for later " swing down."

Fio. 661. Loss of lower two-thirds of nose.
Complete atresia of nose.

FIG. 562, Profile showing the loss of contour.

INJURIES OF THE NOSE

281

(2) Small rod of cartilage was imbedded in cheek on left side for later support to left ala.
Remains of right ala freed and brought down into position. Skin sewn to mucous membrane
all round nasal aperture.

Result. Satisfactory.

10.10.18. Operation. (1) Glabella flap, with its contained cartilage, swung down
inverted. Extremity of flap split into two halves, which were twisted raw surface to raw
surface to make lower part of columella, a small circular area in upper lip being bared to
receive it. (2) Remains of right ala freed and its edge pared. (3) Small flap, with contained
rod of cartilage, turned-up skin surface inwards to form vestibule and support of left ala,
sutured to the skin of flap 1.

Note. The cartilage in flap 1 was now sticking out very prominently, and a portion

Fio. 563. Shows clearly the" establishment of the
nasal airway by scar excision and suture of skin to
mucous membrane. A cartilage rod has been inserted
over the bridge of the nose and glabella, and a small
lamina into the cheek for the ala support.

Fio. 564. Incisions for the next stage : the two flaps
containing cartilage are inverted. The right ala
stump is advanced and the forehead flap brought down.

was excised from the extremity. The lining membrane was completed by catgut suture
of these three component flaps.

(4) Flap of required size cut, brought down from forehead.

Note. Left ala looks exceptionally well.

A special doubling of the extremity of the forehead flap (see diagram) was carried out
with the idea of giving more prominence to the tip.

The immediate effect was bizarre. Forehead closed by approximation.

24.10.18. Progress. Satisfactory. Tip contracting into very good shape.

The pedicle has not yet been dealt with owing, amongst many other things, to the
present influenza epidemic. It is proposed to deal with it by excision, then by replacement,
with the addition of a whole-thickness graft in the upper portion of the scar to allow the
eyebrow to descend.

282

PLASTIC 'SURGERY

Fio. 565. Lateral view before Fio. 566. Suture of the inturned flaps FIG. 567. Lateral view
covering flap is brought down. and advanced right ala. with covering flap.

Note that the split ends of the inturned bridge-flap are turned together so
that their skin surface forms the columella.

Fio. 508. Suture of the frontal flap. The forehead was closed by approximation
the exact lines of this are not indicated in the diagram.

INJURIES OF THE NOSE

283

FIGS. 509 and 570. Views of the nose with the pedicle in position.

FIG. 571. Pedicle returned. FIG. 572. Profile. Compare with original.

Note the slight notch in right ala, which was due to an error in diagnosis of the amount of ala lost.
The new method of making the left ala gave an excellent result, as shown by this case.

284 PLASTIC SURGERY

CASE 365

The first photograph shows early result of a very serious injury. In addition to de-
struction of the left eye, and deformity of the upper eyelid, the lower two-thirds of the nose
was destroyed as well as the pre-nuixilla and the greater portion of the upper lip. There
remained about one-third of the upper lip at the left corner. The condition on arrival,
some twelve days after injury, and that when all wounds were firmly healed, arc shown in the
photographs. On 29.11.17 an operation was performed, as a first stage, on the upper
lip, to construct a bridge on which the new nose could be made.

As no photos of this intermediate stage are available, this operation is not illustrated.
It was intended only as a partial repair of the lip. As regards the rhinoplasty, the
principle of building a double epithelial nose over a mechanical intranasal support was the
one employed, in the hope that more definite shape might result.

The operation was planned on a plaster cast. Into the nasal aperture was fitted an
undermould of the new nose, which was made in hardened wax, having a breathing tube
inserted in its middle. This apparatus was constructed under the direction of Captain
Kelsey Fry and is not illustrated. Over this undermould were swung, first a flap from
above to line the bridge portion and back of columella, and, secondly, two lateral skin-
flaps of special design to line the new ala, the end of the central flap being attached to a
small skin-flap turned upwards from the upper lip. When this had been carefully sutured
together, a piece of cartilage was taken from the rib and a piece of the necessary shape was
sutured centrally to the remains of the nasal bones. Over the whole was brought a frontal
flap. No skin grafting was carried out. The pedicle of this frontal flap was of the imbedded
variety and not bridged over healthy skin.

The result of this operation was very satisfactory. Slight delay in healing occurred
round the margins of the ala, a spot that frequently heals with difficulty.

The mould was retained for some ten days, at which time it was unwisely removed.
This removal allowed the tissues to thicken on the under-surface of the cartilage, and fill
in the cavity ; at the same time, a fibrotic process commenced around the ala and, to one's
disappointment, this result was marred by nasal stenosis, requiring a definite operation
for cure.

A special reimplantation of cartilage was made eight months later, in which one central
rod was supported by two ala rods inserted through the tip. Subsequent to this, all tissues
on the nasal aspect of these ala cartilages were excised and the columella, which was too
short and contracted to allow the tip to rise, was cut across. The whole raw area was skin-
grafted by thin Thiersch graft held in position by a piece of black gutta-percha.

The graft has taken well, and the tip is now upstanding and the airway established.
This case is completed by the insertion of an artificial columella (Captain Kelsey Fry),
which gives support to the tip and a satisfactory appearance. There are no normal tissues
in the neighbourhood from which a columella might be made. A better and quicker result
would have been obtained had the cartilage been imbedded at the preliminary stage on the
usual lines.

Details arc appended.

Condition. Loss of two-thirds of upper lip, lower two-thirds of nose, and pre-maxilla.

29.11.17. Operation. For upper lip. First stage.

At the end of the operation there still remained the provision of the skin for the right
half of the upper lip, for which a bridge-flap seemed indicated : as in view of a later rhino-
plasty, a descending lateral nasal flap was not indicated. The bridge flap was not attempted
at this operation, and the raw gap was closed by drawing up the mucous membrane to meet
the skin on the right side of the lip.

A denture was inserted to support this lip.

J.',.3.18. Operation. Sub-total rhinoplasty varied Indian method.

A hard wax mould was made with the assistance of Captain Fry, in which was imbedded
a small breathing-tube. Over this mould the new nose was made in the following manner.
Three skin-flaps were turned inwards, one from the bridge, and two from the cheek region,

INJURIES OF THE NOSE

285

Fio. 573. Loss of the lower two-thirds of the nose complicated by loss of the pre-masxilla and upper lip.

FIG. 574. The healed condition. The accom-
panying bony and lip destruction makes the
rhinoplasty considerably more difficult.

FIG. 575. Profile view of the lost contour.

28C,

PLASTIC SURGERY

to complete the underlining of the new ala and back of columclla. The lateral Haps were
of special design. These flaps were all sewn together, and the raw area thus created was
covered by a frontal flap. Costal cartilage inserted between the two skin layers in the
centre line. Cartilage extended from the root of the existing nose to the tip of the new
nose. Spare piece of cartilage imbedded. The pedicle was very narrow and was imbedded.
Result very satisfactory. The wax support was removed on the seventh day. It should
have been retained for a considerable time longer, as thickening of the tissues and stenosis
are occurring.

16.4.18. Operation. Return of pedicle to forehead. No skin graft.
3.5.18. Operation. Upper lip. Second stage.

19.11.18. Condition. Result of lip-flap not pleasing at first, later, it settled down.
Nasal stenosis is now almost complete, and the piece of cartilage inserted at rhinoplasty
operation is almost flat on the face and is not acting in any way as a support. It was de-
cided to superimpose another piece of cartilage to give more support and prominence.

19.11.18. Operation. A piece of cartilage from store in abdomen was inserted into
each ala to support the central rod. Diagram of method to support herewith. No attempt
to establish airway.

Result. Satisfactory.

19.12.18. Operation. Excision of scar on edge of ala and of tissue beneath the alar
cartilages, coluniella divided, and raw area beneath tip and ala skin grafted (Thiersch).
Result good.

Kio. 570. Diagram of operation of 19.11 .18, showing implantation of three rods of cartilage to raise and
support the newly made pose, which had sunk on the face so that the airway was occluded.

INJURIES OF THE NOSE

287

Fio. 577. Showing Stent to keep Thiersch graft in position. It is perforated for airway.

FIGS. 578 and 579. Present condition ; patient wearing, temporarily, an artificial columella.

288 PLASTIC SURGERY

CASE 517

This is very nearly a complete loss of nose. This, again, was made with two skin-
flaps without support, and one was astonished to find what a good nose resulted, although,
of course, it was rather shapeless and there was a tendency to stenosis of the nares. Silver
tubes were fitted to keep these nares open, but, in my opinion, they only increased the
cicatricial contraction. It was therefore decided to allow the passage to be temporarily
occluded and to be skin-grafted at a later stage ; also, to build up the contour of the nose
by cartilage implantations. The first and larger implantation had the effect of raising the
bridge without raising the tip. This was three months after rhinoplasty, and the graft
was quite satisfactory and the nose began to have shape. A most disastrous mistake was
made by operating again upon this patient 19 days later. On this occasion, further shaped
cartilage for the tip and lower parts of the bridge and alae was implanted. The wounds
healed well, the stitches were out. and at this time it appeared to be the best nose the author had
ever made. However, on the eighth day after this operation, an abscess formed, and the
last bridge cartilage was evacuated. When healed, the result was most unpleasant, as the
skin was blue and wrinkled ; and I doubt whether the nose will ever be as good again. The
cause of this failure was undoubtedly twofold: (1) operating on the patient too soon;
and (2) irritation and late infection, probably caused by patient.

After a considerable interval further cartilage rods were inserted for the tip and ala
supports, the nasal surface of which it is proposed to epithelialise at a later date, to establish
the airway. Operation details appended :

5.3.18. Operation. Rhinoplasty, sub- total Indian method: a central and two lateral
flaps were turned in.

The extremity of the central one was sutured to the upper lip to form the back of the
columella. Frontal flap superimposed.

N.B. No support in the nose or in the new tissues brought down.

16.4.18. Operation. Pedicle returned.

Right costal cartilage implantation. Two large pieces put in for nose and eye.

Skin-graft over the undisturbed granulations. A piece of whole-thickness skin the
size of a florin was implanted. Its edges were sewn tight to the edges of the wound and a
piece of stent superimposed to put it on tension, the edges being slightly undermined to
retain the stent.

Result satisfactory. Tendency to stenosis of nares. Skin-graft to forehead successful,
pink, soft and mobile.

8.6.18. Operation. A piece of cartilage was taken from subcutaneous store, shaped
in form of rod and inserted from the root of the nose. Balance of cartilage rcimplanted in
subcutaneous tissue. This implantation raised the bridge, but produced a certain amount
of depression of the tip (comparative rather than actual). It had been decided to allow
stenosis of the anterior nares, the passages to be re-established later.

Result. Satisfactory.

27.6.18. Operation. Further implantation of cartilage to give form to the tip and
lower part of bridge and alae. Two long, thin strips were inserted through a vertical in-
cision just below the tip. The skin of the margin of each ala was undercut with a fine
knife as far as the cheek attachment. In these two subcutaneous tunnels the thin bits
of cartilage were inserted. A third main piece was then inserted between the skin and the
previous cartilage rod. which gave a very fine-edged bridge effect. An eyelid plastic was
also performed at the same sitting.

Result. Xo trouble occurred and stitches all out, but on eighth day nose suppurated
and to be reopened (5.7.18). Pus and the last bridge cartilage were evacuated. Drainage.
8.10.18. Operation. Transfer of piece of cartilage from No. 681 for future use.

13.12.18. Operation. The above piece of cartilage was inserted in tip and bridge.
Result" healed.

INJURIES OF THE NOSE

289

FIG. 580. As received into hospital. FIG. 581. Profile healed.

FIG. 582. Healed.

FIGS. 583 and 584. Result of rhino

partia

:'hinoplasty and epithelial outlay for upper lid. Note the defect of the tip and
artial naeal stenosis, for the cause of which see text.

the

290

PLASTIC SURGERY

CASE 23

This patient lost, by shell-wound, all the bony, cartilaginous and soft tissues of the
nose, with the exception of half the tip and the adjacent left ala. This small remaining
portion of the nose had not fallen back, and did not produce the pug type of nostril owing
to the support of a small portion of the septum nasi underneath the tip, from which it ex-
tended backward a half inch.

This case has many interesting features. First, a natural bridge was formed by tur-
binate grafting and advancement, the details of which are set forth later. This turbinate
bridge formed a natural lining to the frontal flap. Secondly, additional support was given
this frontal flap, both in regard to the bridge of the nose and the right ala, by shaped celluloid
plates. These gave trouble and had to be removed. Thirdly, this nose was lined by (a)
mucous membrane in its upper half, and (b) skin in its lower half. This skin was derived
from the extremity of the frontal flap, which was tucked well into the nose. Further, no

FIG. 585. Total loss of nose except left nla and columella.

tendency to contraction or retraction has occurred over the period of observation, viz.
eighteen months : at times the nose has even seemed to grow, and has been whittled down
into its existing and now reasonable proportions. Again, cartilaginous support for this nose
was inserted at a late stage, i.e. after the frontal flap was in position. On the first occasion,
homologous cartilage was used, and the result was apparently satisfactory for about
fourteen days, when the nose suddenly swelled up and about a teaspoonful of pus was
evacuated. Three days later no more suppuration was visible, and after a period of two
months' convalescence there was no sign of the cartilage it had obviously been absorbed.
An autokgous cartilage graft was later inserted. This has, at the time of writing,
been in the nose five months and is obviously permanent. No grafting was attempted on
the forehead, and the resultant scar is by no means offensive. There is no doubt that, by
leaving intact the skin of the left ala and columella. the blending of the forehead flap with

INJURIES OF THE NOSE

291

this skin has been rendered very difficult, and one feels that it is better to utilise remaining
pieces of skin for a lining membrane or to excise them.

In reviewing this case, one feels the correct procedure would have been a reflection of
the surface skin over the left ala towards the right, to skin-line that portion of the new nose.
The flap would have required modification to include the left ala and remains of the tip,
but the natural form of this nostril would still have been kept intact by the supporting
structure, and a more homogeneous appearance would have been readily obtained.

The following are the details of the case :

At an operation performed on 20.6.10 the left middle turbinate was detached, except
at anterior end, swung forward on itself, and stitched to the remains of the septum in order
to build up the bridge of the nose by stages.

On 9.8.16 the right inferior turbinate bone was removed by detaching it posterially
as far as its anterior end, and grafted on to the already partly formed turbinate septum,
i.e. superimposed over the middle turbinate in its new position.

Under local anaesthetic, the anterior attachment of the right inferior turbinate, which
was turned up in previous operations, was freed and sutured to the remains of the tip of the
nose to form a bridge.

A rhinoplastic (three-quarters total) operation was performed on 11.10.16, when a
celluloid plate was first placed from the frontal bone to the tip of the nose over the existing
turbinate bridge and stitched into place. A flap with its base on the internal angle of the
right eye and extending obliquely upwards to the left temple was cut according to the
accompanying shape and dimensions vide diagrams. It was twisted down and sewn
into position. The right ala was formed by curling the tip of this flap over a small celluloid
piece stitched to the tip at one end and to the cheek at the other. No seriovis attempt
was made to close the frontal wound. A relaxation suture from the flap to the left cheek
was inserted.

On 28 . 10 . 16 the frontal flap was cut through at level of eyebrow and also at attachment
to left eyebrow region, and the pedicle returned to the forehead. The newly cut portion

FlGS. 586 and f>87. Indian rhinoplasty over celluloid supports. The lining was provided by turbinate grafts
at the bridge and the infolding of the end of the frontal flap at the vestibule

292

PLASTIC: SURGERY

of the flap was fitted in to form the upper part of the bridge of the nose. In joining this
to the skin above, the nose flap was made to lie underneath the upper skin by cutting both
very diagonally. Conversely, the skin near the eyes was made to overlap the skin of the
nose by similar but reverse method. The nose was not entirely closed on the left side,
and this necessitated a small skin-flap from cheek at a later date.

The celluloid splint was removed from nose on 29.1.17.

On 17.4.17 an implantation of homologous cartilage was performed.' Two lateral
incisions from root of nose up over frontal region were made, flap of periosteum turned
down, and bone chiselled upwards forming a notch. The skin was separated from under-
lying tissues over the whole length of dorsum, rib cartilage inserted, and passed through
a hole in periostea! flap, the upper end of cartilage engaging in notch of bone ; a small
piece of cartilage to reinforce left ala. A small flap was taken from the left cheek to relieve
tension when suturing in this region. The bulk of the right side of nose was reduced by
removing an elliptical piece of skin and drawing the edges together.

A further operation was performed on 18.9.17 for implantation of autologous cartilage
into bridge of nose. The cartilage inserted at previous operation lias become entirely
absorbed and the nose has flattened. The cartilage was inserted from above and went as
far as the tip. The support of the cartilage was made by splitting it so that it straddled
the deep tissues. Its length was about If in. An attempt was also made to make an ala
on the right side. There is still, however, too much tissue on this side. Cartilage taken
from the seventh right rib.

A small corrective operation, performed later, brought this rhinoplasty to its present
condition.

Fio. 58S. The turbinate grafts complete,
forming support and mucous membrane
lining.

Fio. 580. The celluloid strips Imd to be removed
and this globular appearance resulted.

INJUKIES OF THE NOSE

293

FIGS. 590, 591, and 592. After autologous cartilage graft to bridge and trimming of right ala. The forehead

healed by granulation, the pedicle being returned.

294

PLASTIC SURGERY

CASE 132

The treatment of this case by skin-grafting the intranasal aspect of the new nose
marks a definite stage in the advancement of rhinoplasty.

The injury involved complete loss of nose and its supports, together with a large portion
of the left superior maxilla. The appearance on admission after ten days was that of a

large crater in the middle of the face which nor-
mally was filled by the nose.

When the tissues had become healthy, an opera-
tion was undertaken to establish and maintain the
airway ; skin-grafts were applied to the raw areas
after the intranasal adhesions were freed. This
proved a satisfactory procedure, and subsequent
photographs show the complete freedom of the
right nasal passage from stenosis.

The restoration of the nose was then designed,
and a piece of cartilage (the shape of which is well
seen in the photographs and in the diagrams) was
inserted through an incision of the scalp near the
hair-line. This cartilage was taken from the eighth
right rib and was 3 in. in length ; it was split along
the lower border and the two halves separated.
Portions of it were then removed until it took up
the shape as shown in Professor Tonks's diagram,
fig. 594. The terminal portion of the cartilage was
pointed and extended about 1 in. from where the
new alae joined the tip. This prolongation was for
the columella support. The cartilage had a ten-
dency to arch somewhat, and this columella exten-
sion of the cartilage was causing a little pressure
necrosis, so that on 30.5.17 the columella was
divided with a tenotomy knife from its attachment
to the tip, and a small portion of extruded cartilage at the extremity of the cartilage
was cut off. The wound then healed without further trouble.

The next stage of the rhinoplasty consisted in bringing forward, and especially to the
left, portions of the turbinates and septum, so that there should be a satisfactory bed on

FIG. 593. Total loss of nose, complicated
by lateral maxillary and cheek loss.

A. Portion of inferio-
Turbinate bone
swung across.

Fio. .504. Shape of the cartilage and the position into which it was put.

INJURIES OF THE NOSE

295

FIG. 595. Shows the results of the turbinate and septal grafts
helping to line and support the nose laterally.

which to implant the new nose. At this stage a colleague. Major Seccombe Hett, R.A.M.C.,

operated, and a description of the operations is given in the following paragraphs :

1.9.17. Intranasal operation preparatory to plastic operation for complete new

nose. The left middle turbinal was detached from its connections posteriorly and swung

forward, so that its posterior end
was brought in contact with and
attached to the anterior end of
the left inferior turbinal. The
right inferior turbinal was simi-
larly treated, and its posterior end
swung up and attached to the
root of the nose. The cartila-
ginous septum was detached from
the floor of the nose and also from
the vomer. remaining attached by
a pedicle at the root of the nose.
It was rotated and placed laterally,
so that it bridged across the space
between the right inferior turbinal
and the left middle, to both of
which it was attached by cutgut
suture.
2.10.17. Following last operation there is now a mass of tissue filling up the cavity

to the left of the middle line. The posterior end of the right middle turbinal was found to

be firmly attached to the septum. Its anterior attachment was now separated and swung

downwards to floor of the nose and attached there. The result of these procedures was

that a very considerable gain was obtained, as is very evident from the photograph, fig. 595,

which shows well the advance turbinals and septum.

There still remained a big deficiency of the left maxilla, which one decided to fill up with

a large cheek-flap.

Operation (Major Gillies). The skin

and scar tissue lying beneath the left

lower lid was turned in towards the nose

with its skin surface facing backwards ;

the eyelid was thus freed and a large as-
cending cheek-flap, which is clearly seen

in fig. 600, was swung into position.

Thread sutures were used for the deep

muscular sutures, a supply of catgut being

temporarily suspended, and these thread

sutures gave a little trouble, as they tended

to work out through the scar. No general

suppuration, however, occurred.

At the same operation, one decided to
cpithelialise the lower half of the nose
while it was still in situ in the forehead.
The columella and alse of the nose, with
imbedded cartilage, were outlined by in-
cision and raised, and the periosteum
raised for some distance down the fore-
head. An impression of this cavity was
then made in Stent, which was next covered
by fresh Thiersch graft ; it was reinserted

FIG. 5!)f>. View from above forehead. Skin-graft on
the under aspect of the flap and on skull. Photo taken
on the eleventh day after operation. Note : the graft
was so perfect that it could be picked up and sutured
to the skin round the alao.

29G

PLASTIC SURGERY

and the skin sewn up. A little suppuration occurred, and when the Stent was removed
on the tenth day, only that portion of the grafting which lay under the columella had
failed to take ; all the rest had taken in a most remarkable manner, as is evidenced by
study of fig. 596. The epithelium was so good that it could be picked up with forceps
and drawn round the new ala- and sewn to the skin. The stitches arc in evidence in the
figure. It was then hoped to leave the nose for a little while, but, owing to obvious re-
traction and thickening, it was decided to swing it down at once. The further outlining of the
rhinoplastic flap was undertaken on 12.12.17, and followed the lines indicated in fig. 597.

The lower part of the flap had been epithelialised by the inlay ; the bridge part was
lined by turning in small flaps from over the glabella and left cheek. A portion of the
cartilage was exposed and excised at the time of this operation, as it was found that
after the inlay and perhaps even before this stage the cartilage, probably due to pressure,
had been gradually moving its position and coming nearer the eyebrow. This manoeuvre
of exposing the imbedded cartilage and excising a portion of it without prejudicing the
blood supply of the flap, is not a pleasant experience for the surgeon. However, in this

Fios. 597 and 598. Diagrams of the treatment of the pedicle and forehead deficiency by scalp plastic.

particular case no infection or loss of blood supply occurred; but, in view of Case 111 and
others, one is very chary of interfering with the imbedded cartilage until it has been well
established in its new position. Considerable difficulty occurred in getting the pedicle
central as is obvious from the photograph, fig. 600. No attempt was made to bend the
columella which had become very thick and stiff, and it was also found impossible to gel
the frontal flap to join the skin of the cheek near the left ocular angle. The already thickened
and swollen nose became larger, but under the influence of electro-therapeutic measures.
undertaken by Lieut. H. M. Johnston, this nose is assuming reasonable proportions.

Subsequent treatment consisted in the return of the pedicle on 25.3. 18. The operation

was performed under novocaine anaesthesia three months later. Also, under local anesthesia.

various corrective operations were performed to reduce the bulk and remedy small di-

now became obvious that the Thiersch on the forehead, which had been

1 on the bone by the Esser-Inlay method, was remaining depressed and fixed firmly

: bone A plastic operation for its excision was carried out under general anaesthesia

and the scalp advanced to fill up the gap.

Details and diagrams of this operation are appended :

19.7.18. Operation. Under general anaesthesia. Object to remove large depressed
skill-grafted area on forehead and raise eyebrow, etc.

INJURIES OF THE NOSE

297

FIG. 599. Profile showing the
cartilage in forehead.

FIG. 600. The early, very thickened, result.
Note the skin-graft on forehead.

FIG. 601. Profile of same stage.
The columella was so swollen that
it could not be bent into position.

FIGS. 602 and 603. Result of the treatment.

298

PLASTIC SURGERY

Long incision from right eyebrow to top limit of forehead scar followed by the excision
of the remains of the skin-graft and sear tissue. The right eyebrow could now be lifted to
its normal level. In order to get an easy closure of the forehead, an advancing flap from
the temporal region of the scalp was swung down to complete the forehead. Further
plastic adjustments at the root of the nose, combined with an excision of part of the imbedded
cartilage, produced a very much more satisfactory result in the glabellar region. A deep
catgut suture from the tissue overlying the cartilage to the periosteum of the glabellar
region gave a hitch to his nose which lifted the tip and columclla into a very satisfactory
position. It was not expected, however, that the elevation of this would remain so marked
owing to the attachment of the nose to the left cheek.

1.8.18. Progress. Satisfactory. Slight dropping of tip noticed. The total result
to date is sufficiently satisfactory, and is probably capable of much improvement.

FIGS. 604, COS, and 600. Shortly after final corrective operation.

INJURIES IN THE REGION OF THE EYES,
INCLUDING BURNS OF THE FACE, AND
INJURIES TO THE PINNA

CHAPTER VII

INJURIES IN THE REGION OF THE EYES, INCLUDING

BURNS OF THE FACE

THIS section includes not only description of injuries of the orbital ring, of
the eyelids and the sockets, but, in addition, the operative treatment of burns.
The most important and outstanding result of severe facial burns is ectropion
of the eyelids. It was found impracticable to devote a separate chapter to
burns for this reason. The palliative treatment of paralysis of the eyelid muscles
and the principles of otoplasty are also discussed.

For convenience of discussion injuries of the eye region are subdivided
into

1. INJURIES OF THE ORBITAL RING.

2. INJURIES OF THE EYELIDS.

3. INJURIES OF THE SOCKET.

In a subsection of this chapter Burns of the Face plastic operations
on the pinna are discussed.

300

INJURIES IN THE REGION OF THE EYES 301

INJURIES OF THE ORBITAL RING

Many gunshot injuries result in loss of the superciliary ridge of the frontal
bone, the external angular process, the malar bone, and the infra-orbital plate.
With these bony losses of the orbital borders are frequently associated losses
of the lids and damage to the eye and socket ; but in the following cases I have
limited the examples to those in which the repair is mainly centred in replace-
ment of the bony contour. These are among the most satisfactory of the
plastic restorations of the face, and, provided the eye-socket is clean, there is
little risk of infective troubles. However, when the injury involves the frontal
sinuses, care must be taken that the graft restoring the shape does not lie in
connection with the mucous cavity. The restorations have been made mostly
by the aid of shaped cartilage implantations, and almost perfect restoration
of contour has thereby been obtained.

When a larger loss of bone occurs, constituting a cranial defect, the cranial
cavity may be shut off by an osteoperiosteal graft which I have not personally
used or by an extension of the cartilage restoration. It is advisable to work
out, with the aid of the sculptor, the exact amount and shape of the loss, and
to make a metallic model of the necessary implantation before the operation.
This enables one to shape the cartilage exactly at the time of operation.

Frequently it is necessary to replace the eyebrow. The loss of the eyebrow
hair is a serious defect, which may be corrected by the wearing of artificial
eyebrows or tattooing of the skin a quite useful camouflage. Surgical repair
is illustrated by two cases. In one, a whole-thickness free graft from the hairy
scalp over the mastoid, and, in the other, a pedicle flap carrying hair from the
scalp region is grafted into position. Care must be exercised to choose a part
in which the hairs are growing in the right direction.

For the external angular process cartilage is indicated, while for the loss
of the malar the author's temporal muscle-flap is very satisfactory in some
cases, and in others serves as an excellent basis for the addition of a cartilage
graft. Loss of the orbital plate of the maxilla, resulting in a downward dis-
placement of the globe and socket, is remedied by cartilaginous implantation,
sometimes from the rib, and sometimes from the helix or antihelix of the pinna.

302

PLASTIC SURGERY

CASE 307

This sergeant received a shell-wound in the right temporal region, eausing loss of the
outer portion of the superciliary margin of the frontal bone. The healed condition is repre-
sented by a depressed scar which includes the lateral portion of the eyebrow. The scar
was first excised and the level of the eyebrow corrected. A small flap of temporal muscle
was dissected and laid in the line of the wound to restore the contour. The result was good,
excepting a distinct depression of contour, which was remedied later by cartilage graft. At
the same time, a cartilage globe was inserted into the socket to relieve the sunken condition
of the lids. This cartilage globe operation is described under the subsection on sockets.

Operation Notes :

12.7.17. Operation. For the formation of the right superciliary margin and for
excision of scar. Scar was excised. As a small amount of muco-pus appeared on the lower
part of the wound it was decided not to graft any cartilage. In order to make contour,
incision was prolonged downwards towards the temporal region, and flap of muscle was
outlined and swung upwards from its origin and stitched to the subcutaneous tissue of the
eyebrow. In order to get the eyebrow into line, it was necessary to put in a relaxation
suture with plate. Wound edge closed with thread ; drainage provided by silk-worm gut
at each end.

27.10.17. Result of previous operation satisfactory. Slight depression of super-
ciliary ridge. Eye socket sunken.

27.10.17. Operation. Insertion of cartilage globe and cartilage into eyebrow.

Cartilage sphere operation as usual. The cartilage being in one ovoid piece. Small
strip inserted through small incision in right temporal region to complete superciliary ridge.

Fid. 607. Excision of scar, adjustment of eyebrow,
and muscle swing to help fill depression.

Fia. 008. Suture.

INJURIES IN THE REGION OF THE EYES

303

FIG. 609. Healed condition : Outer part of eyebrow raised by soar, and loss of bony prominence.

Front view. Semi-profile view.

Fios. 610 and Gil. After excision of scar and cartilage graft.

304 PLASTIC SURGERY

CASE 558a

A severe gunshot injury carried away a large portion of the frontal bone and the eye-
brow. The eye had been destroyed or removed prior to this patient's admission. In
addition to the destruction of all the superciliary margin, there was a cranial defect of about
the size of a florin. The main scar ran along the centre of a depression from the inner edge
of the ridge to the external angular process, which was also partly destroyed.

The interest of this restoration centres in an accident which happened to the cartilage
graft and in the lesson it taught. A very exact estimation of the amount of cartilage to
restore the contour was first made and the model cut into two pieces, so that it could be
reproduced from adjacent ribs. The cartilage was shaped satisfactorily and inserted through
the end of the scar over the external angular process. The rest of the scar and skin was
elevated by undercutting until it could be stretched forward to contain the cartilage.

A very perfect restoration was the result. Hasmatoma and infection followed, however,
and owing to the exposure of the dura mater, it was expedient to remove the cartilage and
avoid possible risk of meningitis.

There is no doubt that (1) a preliminary plastic should have been done to reduce the
scar and to provide more lax healthy skin to nourish the cartilage ; (2) there is always a
certain amount of danger of haematoma in these undercutting operations done through a
small incision, and a more open type of operation is better.

This infection of the cartilage was the first accident. It was decided to boil this care-
fully shaped graft for five minutes, after which it was inserted subcutancously over the
abdomen, where the implantation wound healed satisfactorily. A piece of this was retained
for histological examination. It should be noted that a cartilage globe was inserted at
the back of the left eye socket, which was entirely satisfactory.

After due interval a plastic was performed on the forehead for excision of the dense scar
and for advancement in a downward direction of the forehead and scalp, so that more
skin was brought into the eyebrow region. This having healed satisfactorily, the original
shaped cartilage was removed from the abdominal wall, and a bed made for its reinsertion
into the forehead. It was observed that the cartilage had the same appearance in shape
as when it had been last seen some nine months previously.

While the bed was being made for it, the cartilage was laid in a swab on the instrument-
table, and its second accident then occurred. One of the attendant " scavengers " of the
theatre zealously removed, with sterile forceps, what was considered to be a dirty swab,
and the precious cartilage found its way to an unsterile bucket. It seemed probable that
the cartilage had touched nothing unsterile, hence it was removed from the bucket and,
without further incident, was inserted in its bed. No further untoward symptoms have
occurred. There remains the provision of an eyebrow to complete the case.

Operation notes :

23.5.18. Operation. Method of treatment. The necessary amount of cartilage to
restore the contour was accurately gauged on a plaster cast, and a composition model thereof
made in two sections by Major Dorrance, M.R.C. The two halves were made so that they
could be reproduced from ordinary rib cartilage.

(1) Incision made above remains of eyebrow at outer angle and also above depression
at inner side. From these two incisions the skin was undercut, care being taken not to
wound the dura mater. This elevation of the skin was tedious. Cartilage was taken from
right thorax, shaped by Major Dorrance to pattern. These were slipped in through the
outer incision, producing a perfect restoration of contour.

(2) A globe of cartilage was inserted through the conjunctiva in the usual manner into
left socket.

Result. Hacmatoma occurred in forehead, followed by temperature and pain. Owing
to the proximity of the dura mater and the continuance of slight temperature the cartilage
was removed (27th) under general anaesthesia.

The surface of the cartilage in two or three places was covered with lymph, showing
early infection, and culture showed presence of streptococci. A small portion of infected

INJURIES IN THE REGION OF THE EYES

305

cartilage for section was "sent to Professor Keith.
The rest of the cartilage was boiled for five minutes
and reinserted into abdominal wall. Subsequent
progress satisfactory. Cartilage remains same size
and shape to date 1.7.18 no absorption having
yet occurred.

9.9.18. The cartilage graft in the abdominal
wall appears satisfactory and undiminished.

9.9.18. Operation. It was decided, in order
to make a good bed for the cartilage, to advance
the scalp to bring sufficient skin into superciliary
region. The scar tissue was freely excised in this
area, and from the inner extremity of this incision
the knife was carried up over the forehead and scalp
for a distance of two inches from the hair-line. An
abrupt " V " was then made to the left, and the
knife carried down as far as the left temporal
region. This enabled the whole of the forehead to
be suitably advanced. Closure resulted in a " Y '
suture.

Note. The dura mater was not exposed during
this operation. Primary healing.

12.1.19. Operation. Under general anaesthesia
the cartilage in the abdominal wall was removed.

(It should be noted that the graft appeared
much the same in shape and character as when it
had been inserted after boiling on the occasion of
the second operation. Piece taken for section.)

A flap was next turned up by long incision extending across the whole area, so
that free inspection of the bed could be made. Cartilage inserted and skin sewn up.

24.2.19. Result. Restoration appears quite satisfactory, and no rise of temperature
occurred. A slight deficiency in the contour is noticeable in the middle of the area.

Fio. 012. Cast of healed condition, showing
loss of superciliary margin.

FIG. 613. After second plastic in which forehead
skin was advanced to provide a good bed for the
cartilage graft.

FIG. 614. Final ; Contour improved.

306 PLASTIC SURGERY

CASE 929

This officer patient shows a very similar injury to the previous case, but the scar is
well up on the forehead and the eyebrow is intact. A larger cranial defect is present through
which the pulsating dura mater is plainly visible, and the external angular process has
also been shot away, together with a portion of the malar region. The socket holds an
artificial eye, but this eye is turned latcralwards. Another feature about the cranial defect
is that the depression is very considerably diminished when the brain is under higher pres-
sure ; the two plaster casts illustrated show this difference in contour, due to differences
of the intra-eranial pressure. The first stage of the reconstruction has been carried out
by implantation of cartilage graft from adjacent ribs. The scar on the top of the forehead
was utilised for the incision of a flap which provided a clear view of the operation area.
A little more of the external orbital ring remains to be built up by the aid of spare cartilage,
which was taken at the time.

27.1.19. Operation. General anaesthesia. Incision over the right rectus and ex-
posure of the cartilage area. The attached adjacent portions of ribs 7 and 8 were removed
also a spare piece. Wound closed and spare piece inserted subcutaneously. Two joined
cartilages were properly shaped. Incision over the left forehead along the line of
the scar, curved downwards at each end so that full exposure could be obtained. The
skin was very carefully undercut, so as to avoid wounding the dura mater, which was closely
adherent. The flap was turned down and all bleeding points stopped. Cartilage inserted,
and sewn down by cutgut to the periosteum at each end and the wound closed.

Result. Wounds healed by first intention.

Complication. Influenza developed third day.

FIG. 015. On admission.

INJURIES IN THE REGION OF THE EYES

307

FIG. 016. Cast taken while intra-cranial
pressure was raised.

FIG. 617. Cast while intra-cranial
pressure was low.

FIGS. 618 and 619. After cartilage implantation.

308

PLASTIC SURGERY

CASE 75

In this injury the loss of the bone is considerably loss and there is no cranial defect,
but the eyebrow lias been destroyed over its outer two-thirds, its place being taken by a
dense scar which also runs across the external angular process to the cheek. The left eye
socket, which was carrying an artificial eye, is considerably depressed.

FIG 620. Temporal flap outlined.

FIG. 621. Suture.

The reconstruction of the eyebrow was first
attempted by use of a flap, which is seen in the
diagram. It was cut from the left temporal
region, where the hair grows in the requisite
direction. Fig. 623 shows the bridge pedicle
flap in position ; this was not tubed. Uoth
the flap operation and the return of the pedicle
were performed under local anaesthesia (infiltra-
tion Kerocain).

The further stage of this case will include
the raising of the socket by cartilaginous im-
plantation, for which the spare pieces were
taken.

l-'i'i. (>ii. Healed condition (scalp prepared
tor operation). Outt.- two-thirds left eyebrow
missing.

INJURIES IN THE RECxION OF THE EYES

309

FIG. 623. Bridge-pedicle temporal flap in position.

FIG. 624. Pedicle returned.

FIG. 025. To show minimal disfigurement by
pedicle scar.

FIG. 020. After cartilage implant to malar region.

310 PLASTIC SURGERY

CASE 518

This case is unfinished, but is of considerable interest because of the eye socket. The
original picture, fig. 627, shows that the whole of the malar and a very large portion of the
upper part of the left superior maxilla have been destroyed.

The large gap in the cheek contour has been remedied, to a very great extent, by a
temporal muscle-flap, while the necessary skin has been brought down from the left temple
region. Although the socket is not yet up to a normal level, a most satisfactory improvement
has been effected.

At this officer's own request, his final treatment has been deferred for two or three
years. It will probably consist in the reconstruction of the nose and the support of the
left eye socket by cartilage implantation.

Operation notes :

21.3.18. Operation. Restoration of remains of nose to normal position. Complete
separation was made between the remains of the cheek and the nose on the left side. The
alsc were freed of their attachments and the nose elevated, retained by a head-nose ap-
paratus (Captain Fry).

An effort was also made to raise the bridge of the nose by an osteotomy of the right
nasal process through a separate incision. Nasal passages were partly re-established.

21.4.18. Progress. Head -gear discarded and lateral spring apparatus fitted (Captain
Fry).

20.7.18.- The parts of the nose remaining are in good position, with tip depressed.

20.7.18. Operation. Plastic on nose, replacement of eyelids, filling in cheek depression.

Remains of left ala, which was attached to the nose, was divided from above downwards,
about f in. turned downwards and outwards. Triangular flap, with its base at the margin
of the nasal fossa approximately 1 in. x l in. was elevated from the cheek and sown
to the nose to make the inner lining. It consisted of skin with a good many scars. The
previously detached ala was sutured to the anterior margin of this and to a raw area on
the upper lip.

A semicircular incision extending from in. above and to the inner side of the inner
canthus downwards and outwards on the line of an old scar to a point an inch external to
the external canthus.

The upper and lower flaps were elevated, leaving a depressed area approximately 1| in.
in width.

The lower eyelid was now sutured to the inner end of the above described incision, in
this way returning the eyelid to more normal position.

A skin-flap was now elevated from the left frontal and temporal regions, with its base
extending forward for 1| in. from the upper margin of the left ear. This flap Avas long
enough, when reflected, to reach the side of the nose and cover the exposed area below the
eye. This flap contained the temporal artery. The anterior half of the temporal muscle
was now elevated from its fossa, the superimposed fascia divided where it was originally
attached to the zygoma. A tunnel was now established beneath the scar tissue, which
represented the original position of the zygoma, and the muscle was drawn through this
tunnel to fill completely the depression under the eye. The temporal muscle was then
sutured over this muscle to the margin of the skin. The skin margins of the frontal and
temporal regions were undermined and approximated in the frontal area. The temporal
area will be filled by return of pedicle. Operative result very satisfactory.

5.11.18. Operation. Return of pedicle to temporal region (local anaesthetic).

6.12.18. Operation. Excision of scar, together with a small plastic on the left ala
in order to improve the airway.

Patient now wishes to return to civil life. The cartilage to nose and lower eyelid have
therefore been postponed. Rest of cheek plastics very satisfactory, the very large depression
having been completely filled.

INJURIES IN THE REGION OF THE EYES

311

FIG. 627. Healed condition : Loss of prominence of infra-orbital margin,
distortion of nose and stenosis left naris, malposition left lower lid.

Fio. 628. Infra-orbital depression almost overcome by temporal flap. Xose straightened and
naris remade. Lower lid replaced. Case unfinished : for cartilage implants later.

312

PLASTIC SURGERY

CASE 40

This case has been illustrated in the section on cheeks, and shows loss of the orbital
ring through depression of the malar, together with dragging downwards and outwards
of the outer canthus. It is cured by the author's temporal muscle-flap, for details of
which see Section on Cheeks, Case 40, p. 54.

l'ic. (129. Depression in malar region.

Fia. 630. Depression relieved by temporal muscle swing.

INJURIES IN THE REGION OF THE EYES 313

INFERIOR BLEPHAROPLASTY

The following seven cases show more or less severe injuries of the lower
lid, with loss of the lower lid and traumatic cctropion.

Where the loss of the lid-edge is one-third or less, a very satisfactory repair
can be made, but where the whole lid has been destroyed the operation results
seen by the author are considerably wanting in finish.

Of the various methods of blepharoplasty used by ophthalmic surgeons
after tumour removals, however, few seem to have recognised the principle
of providing all the elements of the lid that is to say, lining membrane, support,
and skin covering. Mellor (Vienna) uses free transplants of skin and cartilage
from the ear, which are attached to the back of the external flap. Pro-
vided the graft takes, this should give an excellent result. Eversbusch has
used a pedunculated flap, which is previously skin-grafted before being brought
into position to form part of a lid. But the other standard operations for
blepharoplasty would not appear to have embodied the principle of providing
an epithelial lining. The author wishes to point out that he has had little
experience of reforming lids when a functional eye is present, and the majority
of the cases under construction arc those in which the eye has been destroyed
or removed. Consequently, the value or harm of the presence of a skin surface
towards the cornea cannot be discussed ; but, when the socket is empty, the
author is strongly of the opinion that all three elements of the lid should be
embodied in the reconstruction. Just as in rhinoplasty, skin lining, cartilage
support and skin covering were found to be essential both for preservation
of form and function. So in the lid the best results are obtained when this
principle is carried out. The method preferred is that illustrated in the diagrams
attached, and it is exactly comparable with the author's skin cartilage swing
which has been so satisfactory with the nose.

The operation is divided into two stages. In the first stage, cartilage,
either from the ear or from the ribs, of a suitable length and thickness, is inserted
beneath a flap extending outwards from the outer canthus. When the cartilage
has received its new blood supply the combined skin- cartilage flap is raised
and swung in on a hinge near the canthus. The skin comes to form the lining
of the new lower .lid and the cartilage is now on its anterior aspect, and the
lower border of the skin flap is carefully sutured to the remains of the conjunctiva
to complete the socket. There is now a raw area double the size of the flap,
and it may be dealt with in the following ways :

(a) The cheek wound may be closed by approximation and the lid portion
Thiersch-grafted.

PLASTIC SURGERY

(b) A descending temporal skin- flap may be swung down to cover both

defects.

(d) A double pedicle flap may be taken from the upper lid (Tripier) ; or

(e) The skin may be conveyed to the lid by a tube-pedicle from the neck

(author's principle).

When an eyelid repair is carried out at the same time as a rhinoplasty
an additional piece can be added to the rhinoplastic flap to provide the necessary
skin for the lid.

In regard to the skin-grafting methods for lids, no advantage over the
Thiersch graft would appear to result from the use of Wolfe graft. Where
there is no other deformity in the neighbourhood of the lid the skin-grafting
method produces least additional scar.

Fid. 631. Flap partly outlined.

Fia. 632. Cartilage being implanted.

INJURIES IN THE REGION OF THE EYES

315

FIG. 033. End of first stage.

Fra. 634. Cartilage-bearing flap outlined.

FIG. 635. Lining and support provided.

FIG. 636. Skin covering by free graft.

FIG. 637. Skin covering by flap.

FIG. 638. Suture.

816

PLASTIC SURGERY
INJURIES OF THE EYELIDS

Tim r rases arc shown in this group to illustrate the attempted replacement
of distorted eyelids.

CASE 699A

Severe injury lias occurred to the left eye socket and region of the frontal sinuses.
Cranial defect was present, and pulsation could be felt on the inner 1 wall of the left orbit.

It is difficult to conceive how the upper lid had become adherent at such a low level.
A considerable portion of the lower lid edge was still present, concealed in a pocket beneath
the upper lid.

An incision was made for raising the upper lid, and a flap including the remains of
the lower lid was swung upwards and inwards from the cheek. Cartilage was taken
from the right costal region, and imbedded for future use. Some will be used to cure the
glabellar depression, while further support to the socket and lower lid will be furnished by
the remainder. Hchind the new lower lid an epithelial inlay (Esser) has been carried out,
and a picture, fig. 640, shows, in position, the vulcanite retention apparatus to prevent
the graft from shrinking until the artificial eye is fitted.

Operation notes :

10.9. 18. Operation. Incision made from the inner end of left eyebrow to the attached
inner end of the upper eyelid, so that this could be completely freed and sewn at a higher
level. The socket was completed by excising adherent scars and swinging a flap to
lower lid. Cartilage from costal wall was taken to aid in the reconstruction of the various
depressions and imbedded in abdominal wall.

Kesult. Satisfactory. Wound healed by first intention.

Complications. Acute lobar pneumonia. Recovery.

20.12.18. Epithelial graft to left lower lid.

l-'l'i. ''''lit. OIL M.lmijMioil.

Fio. 040. After lid plastic : Vulcanite in socket
to control Tliiorsch graft lining lower lid.

INJURIES IN THE REGION OF THE EYES

CASE 43

317

This case has been described under " upper lips," but this patient also had derangement
of the left upper lid, which was adherent at a level lower than the lower lid. The inner
canthus was also displaced, downwards and outwards. By means of the Z incision, shown
on the diagram, fig. 642, the upper lid and the inner canthus were replaced in nearly normal
position.

FIG. 641. Healed condition

FIG. 042. Incision.

FIG. 043. After plastic to lid.

318

PLASTIC SURGERY

CASE 318

The third case shows a more severe injury of the malar and infra-orbital region, which
resulted in considerable displacement outwards and downwards of the lower lid.

The main restorative operation consisted of excision of scar, the bringing down of a
temporal muscle flap, and suture of cheek-flaps over this muscle transplant.

Tliis procedure reduced the case to one of ectropion. The lid was really more drawn
away from the socket than everted. A cartilage rod was fitted in subcutaneously along the
lower lid. It effected a very considerable improvement, both in raising in the lid and in
approximating the conjunctival surfaces. There was still, however, an imperfect apposition.

6.9.17. Operation. Loss of superior maxilla, orbital plate, and part of malar and
lower lid. Large scar had to be excised first. Two cheek-flaps were outlined for the skin
covering (see fig. 645), shaped temporal flap turned down, and the anterior portion of
muscle was swung forward over the remains of the malar-bone and sutured under the eye.
The wound was closed in the usual manner, and a long relaxation suture was passed to the
eyebrow.

The result is not likely to be more than a good basis for further work.

19.11.17. Condition. Very satisfactory. Ectropion of lower lid which falls away
from eye.

19.11.17. Operation. For lower lid. (1) Implantation of small piece of cartilage
to stiffen lower lid. (2) Small plastic tip of nose.

Fid. 644. Condition.

Fia. C45. Excision of scar, outlining of skin flaps,
and muscle-swing.

INJURIES IN THE REGION OF THE EYES

319

C AT

t Sopporf low.r |i4.

FIG. 040. After first plastic.

Fia. 047. Cartilage graft to lower lid and small nose
plastic.

FIG. 648. Final.

PLASTIC SURGERY

CASE 603

Tliis officer is wearing a right artificial eye, and the left lower lid is the seat of a eicatrieial
ectropion combined with loss of about a quarter of the lid edge.

In this type of injury it has been found of great value to support the reconstructed lid
by 'ocal fat-flaps turned up from the neighbouring region. These fat-flaps are sutured,
if possible, to the periosteum over the neighbouring bones, so as to help to raise the lid.

In this particular ease, after excision of the scar, deep tissue flaps were raised from
beneath the margins of the wound and sutured across the area of the depression thus
one from over the malar bone was swung across towards the inner canthus, while the other,
from the infra-orbital region, was swung across towards the outer canthus, a deep catgut
suture fixing them to the periosteum. In addition to the excision of the scar an appropriate
cut was made to allow an adequate swinging advancement of the flaps.

In fig. 651, which represents the result some three weeks after operation, it will be
noted that the lid-edge has a notch and a depression at the line of suture. Neither of these
deficiencies was present at the time of operation, and it was interesting to note that, after
an interval of four months, in which massage and movements had been undertaken, that
both these minor defects have been rectified. The result, therefore, is one which is very
nearly perfect. It will be observed, however, that the outer canthus has been displaced
mesially, which is due, of course, to the suture of a lower lid from which a portion was missing.
In this operation I had the valuable assistance of Lt.-Col. S. H. McKec, C.M.G., C.A.M.C.

Operation notes :

22 . 6 . 18 . Operation. Free excision of scar, which was continued up to the conjunctiva.
It was decided not to cut any flaps on this occasion ; but to support the lid in its new position
two fat-flaps were raised from the malar and infra-orbital regions and sutured together.
(Lt.-Col. McKec assisted at this operation.)

Immediate result very satisfactory. Later, a slight dragging downward, owing to
some remaining scar-tissue, is occurring.

!':. 049. Healed condition.

INJURIES IN THE REGION OF THE EYES

321

FIG. 650. Excision of scar and subcutaneous fat swings

FIG. 651. Final. (Intermediate stage mentioned in
text is not available.)

PLASTIC SURGERY

CASE 123

The inner half, or more, of the lower lid has been destroyed, while the remaining outer
portion is caught up in a deep depressed scar descending from the socket to the cheek, pro-
ducing a cicatricial cctropion. There was also loss of the infra-orbital bony support.

The method of repair was by flaps, of which the outer consisted of the normal remaining
lid. At the junction of the skin and the mucous membrane, on the inner quadrant of the
defect, there was a distinct edge, which was utilised to form the new lid margin of the inner
half. It contained, of course, no eyelashes. The conjunctiva and skin-covering for the new
lid were thus provided, and the support was obtained by the use of subcutaneous tissue-
flaps, which were brought up beneath the new lid and sutured to the periosteum in such
a way as to raise and support the flaps. A secondary defect now existed beneath the new
lid, and, in order to take off any tension, an advancing flap was made from the cheek. This
was first held well up in position by deep catgut suture, which took its purchase from the
periosteum in the inner canthus region. By this careful suturing of the flaps, the subsequent
retraction was reduced to such small extent that a very satisfactory lid was produced and
an artificial eye could be worn. A homologous cartilage globe was later inserted behind
the conjunctiva, to give more prominence to the artificial eye (eight months after the plastic).
The final photograph, taken a year after the plastic, shows the result of both procedures.
Both movement and projection of the eye were good. Diagrams of the flaps used in the
first operation (9.2.17) are shown, fig. 653. The special arrangement of the subcutaneous
tissue is not, however, illustrated, but the manner in which flap B, C, raises and supports
flap A is graphically described. Condition eight months later, and second operation notes
are appended :

26. 10. 17. Condition. Result of previous operation good. Scars have become almost in-
visible, but a notch is present in lower eyelid and the eye is not sufficiently mobile or projected.

26.10.17. For projection and mobility of artificial eye. Homologous cartilage
globe inserted under cocaine anaesthesia. The conjunctiva was packed with 20 per cent,
cocaine and horizontal incision made in it. The cartilage globe inserted in two pieces in
the form of a cup and ball, and the mucous membrane stitched with horsehair.

Fio. 65?. Healed condition.

INJURIES IN THE REGION OF THE EYES

323

Note. Some pain experienced.

Result. Owing to not having quite separated the deep tissue sufficiently there was a
little tension on one stitch, which gave way, and a small piece of cartilage became exposed.
This is healing. (20.11.17.)

10.1.18. Artificial eye fitted.

FIG. G53. Excision of scar and outlining of flaps.

Fid. 654. Suture.

O. 053. Immediately after plastic.

FIG. 656. Final.

.-{_' I

PLASTIC SURGERY

TWO MPS of 1 remaining portion* oV

lw*r lid . Deficiency of pAlpcfer*l

sbi(t>d from rb cenfre o\- th lid folh'n*nr

hide where \f% absence should btlrss nofice&b!.

\ \

CASE 356

This minor injury of the lower
lid resulted in the loss of the
middle half of the edge. Its repair
was carried out in the form of a
compromise, thus : a small stump
of the lid -edge at the inner canthus
was freed by an incision extending
down the cheek from the inner
canthus, and another parallel to it,
starting opposite the free end of
this remnant. It could then be
swung across to meet the normal
lid-edge of the outer remaining
portion, to which it was sutured.
The idea of doing this was to
transfer the deficiency of lid from
the centre, where it was very
noticeable and left the globe con-
siderably uncovered, to the inner
canthus region in which its loss
would appear to be of less conse-
quence. The eye, before and after,
is illustrated.

Flo. 657.

Fio. 658. Healed condition.

Fio. 659. Defect camouflaged by translation nearer
inner canthus.

INJURIES IN THE REGION OF THE EYES

325

CASE 511

A companion case to the previous one is shown here. But in this instance the direction
of the wound is different, and the inner half of the lid remains while the outer has been
destroyed. Free excision of scar was carried out as usual. The lid was raised into
position, and a descending flap from the upper lid brought down with its pedicle at
the outer canthus. Similarly, a cheek-flap was swung inwards to fill up the gap previously
occupied by the scar. The subcutaneous tissue was again manipulated to form a support
of the lid. The result was sufficiently encouraging, as the level of the new socket was good.
However, as fig. 661 demonstrates, the outer canthus was considerably contracted. An
Esser inlay was therefore carried out, and the extent of the skin-grafted cavity, prior to

Inla

y
fri

5ock?t.

o&Uiorc

external Incision. .
/

FIG. 600. Healed condition.

FIG. 661. After first plastic.

FIG. 662. To indicate epithelial inlay.

removal of the model, is shown in outline, fig. 662. This grafted area ran externally to
the existing canthus, so that, in addition to deepening the lower fornix, the canthus should
be split open to a greater extent. The epithelialisation of the pocket was very satisfactory,
and an artificial eye was carried comfortably. The last photograph was taken two and a
half months after the inlay, and shows only a minor effect in contour of the lid.

FIG. 663. Before canthoplasty.

FIG. 604 Final.

3-20

PLASTIC SURGERY

CASE 81

This is a class of case in which satisfactory results have not been obtained in our ex-
perience.

There is ptosis, lymph-oedema, and immobility of the upper lid, whose edge is also
partly destroyed. The whole of the lower lid, together with a considerable portion of the
bony ring, ha's been shot away. The fig. 669 of the result is more flattering than was the
actual appearance, and the procedure is hardly justifiable in the majority of cases, unless
an operation for ptosis can be satisfactorily added to elevate the upper lid. The lid may
also be held up by studs on the artificial eye.

Strange to say, this patient, with a fixed staring eye whose level was considerably
below its opposite member, expressed himself as being very pleased with the result, and
would not wear a shade. More especially with the eye than with any other restoration
of the face, does an inferior result give dissatisfaction to the patient, and as the eye is easily
covered with a shade that looks well, anything short of a perfect result is frequently wasted.

The justification for such operation lies in the possibility that the first result may
be converted into a success at some future date.

The first two operations were done in conjunction with Captain Williams, the
ophthalmic specialist, who designed the temporal flap " A " in the diagram.

29.9.16. Operation. Excision of scar. An attempt was made to form the lower
lid by sliding and undercutting the mucous membrane of the upper lid and stitching it to
the freshened edge.

1.12.16. Operation. An incision was made on the upper border of the eyelid and
undercut to the depth of \ in. The scar, which radiated from the external angle was ex-
cised, and a flap 4 in. long from the right temporo-frontal region was cut, its base including
the temple artery. This was freed and brought down to form the inner surface of the
lower lid. Two deep blanket sutures were put in to hold the inner border of this flap down
to the bottom of the socket, and brought out about one inch below the new palpebral margin
and tied over a piece of gauze, the outer edge of the flap was accurately stitched to the
split and loosened lower lid, the rest was sewn up accurately with drainage at its outer part.

Fio. 005. Shortly after wound.

Fid. 666. Healed condition.

INJURIES IN THE REGION OF THE EYES

327

28.4.17. Result of the operation 1.12.16. Satisfactory in that it held an artificial
eye, but too much of this eye was exposed.

28.4.17. Operation. An incision was made along the summit of the skin forming the
lower lid and carried into the socket near the outer angle. This released a flap of skin with
its raw surface outwards, which was sutured to the freshened outer angle. Considerable
gap was thus formed in the lower lid, which was covered in by a free skin-graft from the
right mastoid region, including a few lines of hair.

Result. Partially successful.

Fio. 667. Flap.

Fio. 668. Suture.

Fio. 669. Unsatisfactory result.

328

PLASTIC SURGERY

CASE 227

This is shown as it illustrates the condition of lymph-oedema of the lower lid. I have
not seen one of these persist after excision of the scar has been efficiently carried out. Flap
is indicated in the outline.

Fio. 670. Healed condition.

FIG. 671. Excision of scar and swinging of cheek flap.

Fio 672. After excision of scar.

INJURIES IN THE REGION OF THE EYES 320

SUPERIOR BLEPHAROPLASTY

Two cases of this reconstruction are included in this series, and both, to
all intents and purposes, show losses of the whole upper lids.

Two minor injuries, with traumatic ectropion of the upper lid, occurred
in Cases 365 and 517. See pp. 284 and 288.

No. 365 was treated by flap operation and resuture, while No. 517 was
treated by the epithelial outlay method, which will be described under " Burns
of the Lid " in the next section.

For the total reconstruction of an upper lid in which the conjunctiva is
united by scar tissue to the eyebrow, an extension of the outlay method is
suitable. The lid that results is mobile, and in the position of rest covers
the artificial eyes satisfactorily. It is not long enough to close over the globe
in normal position the movement upwards by the remains of the levator
attachment is, however, quite observable. The most serious deficiency of the
operation is the absence of the eyelashes. The latter defect can, I am sure,
be diminished by tattooing the lid-edge, or by the use of grease paint. In
one case a line of hairs from the eyebrow was included in the new lid, but the
result was not very good. The author has no experience of implantation of
single hairs to form an eyelash. When the loss of the upper lid involves more
of the conjunctiva than of the skin the latter tucks itself in beneath the roof of
the orbit. To form an eyelid from this condition, attempts have often been
made to undercut the skin from the conjunctival aspect, and to epithelialise
its back surface after the method of Esser. For this condition the author
has advised the implantation of auricular cartilage into the skin remains of
the lid, which is subsequently swung downwards as a combined skin-cartilage
flap, similar to the author's other skin-cartilage " swings."

The original skin surface would thereby line the new lid, and a new external
covering provided by skin -graft would form an efficient covering to prevent
contraction. The author has not performed this operation, but has advised
it, and it would seem a reasonable procedure. From the use of a frontal flap
no movement in the lid could, of course, be hoped for, unless either the levator
could be attached to it or a muscle strip introduced.

330

PLASTIC SURGERY

CASE 634

The loss of the upper lid due to this injury is sub-total, since a minute portion of the
lid-edge remains at the inner eanthus. The eyebrow has been partly destroyed and is the
seat of a large depressed scar. The lower lid is normal, but the outer eanthus is caught
in scar.

The method of treatment consisted in the use of an Esser skin-graft for the author's
outlay operation, described in the section on " Burns." The first graft that was inserted was
too short, and a second one was added. The deficiency of the eyebrow was corrected by
a whole-thickness free graft of hairy scalp taken from behind the right ear. The graft was
successful, and probably about half the hairs continued to live and grow in the right direction.
The final photograph is taken without any darkening of the new lid-edge ; but the effect
of the eye was markedly improved when a dark line was drawn along the part where the
eyelashes should be. Operation notes follow :

20.3.18. Operation. Epithelial outlay for new upper lid (partial). Excision of scar
on eyelid and eyebrow.

2.4.18. Operation. Removal of inlay.

Result. Partially satisfactory. The amount grafted was too small and showed tendency
to retract.

13.5.18. Operation. Further to lengthen eyelid by outlay. Incision made above
previous graft. Large inlay inserted.

18.6.18. Operation. Palpebral fissure widened under local anaesthetic.

20.8.18. Result of last epithelial outlay satisfactory. Lid rather too long.

20.8.18. Operation. To correct loss of eyebrow hair. Excision of scar in region of
eyebrow. A free graft of whole-thickness skin from behind the right ear was cut to requisite
size. Hairs had not been shaved but clipped moderately short, and their direction calculated
to be correct when grafted into position. The fatty tissue was scraped off the back of this
free graft. Its length was that of an entire eyebrow, and less than \ in. in breadth. It
was sewn into position. In order to keep it firmly down and on tension, a stent mould
was laid over the graft and catgut sutures were passed over this mould from skin to skin
to retain it in position.

Stent removed eleventh day. Graft appears satisfactory.

Fio. 073. Loss of upper lid and middle one-third
of eyebrow.

FIG. 074. After epithelial outlay to lid, and whole
thickness scalp graft to eyebrow.

INJURIES IN THE REGION OF THE EYES

331

CASE 394

In this case there is absolutely no remnant of the upper lid remaining, and the con-
junctiva has been drawn up by scar tissue to the eyebrow, which in its turn has been dragged
down. The lower lid is normal.

The Esser graft was used by the author's outlay method, a few of the eyebrow hairs
being included in that portion which was taken down after the graft had been made. A
photograph of the result was taken six months after the operation. Though by no means
perfect, it was distinctly gratifying.

The condition is, obviously, capable of improvement, but the exigencies of the Service
demanded this officer's return to duty.

19.12.17. Operation. For formation of upper eyelid. Method: reverse epithelial
inlay. Incision made through the lower part of the eyebrow to include a few hairs, and
laterally towards each ocular angle about two millimetres above the muco-cutaneous junction.
Incision deepened with the knife, which was carried in the soft tissue lying between the
conjunctiva and the floor of the frontal sinus. Impression of cavity taken in the stent and
epithelial inlay made in usual manner. Incision closed.

Eleventh day. Incision under local anaesthetic along original incision. Removal of
stent two days later. Perfect epithelialisation.

Complication. Acute tonsillitis. Area of graft removal slightly infected.

4.1.18. Operation. Insertion of glass shell. Upper lid looks fairly satisfactory.

22.4.18. Result of previous operation satisfactory except for small central portion,
which did not take. This prevented the new eyelid from descending in its central part.

22.4.18. Operation. Plastic upper lid. Excision of diamond-shaped pattern of scar
tissue caused by failure of graft, which allowed lid on resuture to descend. Scar at inner
canthus also excised. Note re skin-graft first operation. The graft was very thick and
has grown hairs all over it. The patient has had a severe septic throat, followed by a septic
area at the place where the graft was taken.

Present condition. Very satisfactory. Discharged to duty, 5.6.18.

Fia. 675. Total loss of upper lid.

Fid. 676. After epithelial outlay.

332 PLASTIC SURGERY

INJURIES OF THE SOCKETS

Plastic problems in connection with the empty socket are mainly of two
varieties. In one very large series of cases common to all war-injury eye clinics,
there is a deficiency of conjunctiva causing entropion and contracted socket.
The other class of cases, which is not so confined to war injuries, presents a
sunken socket, in which the artificial eye sits far back and immobile. In the
contracted socket a deficiency of lining membrane may be present in either
the upper or lower cul-de-sac.

In cases where the lower cul-de-sac is flattened out until it is on a level
with the lid-edge a flap of mucous membrane attached to the lower lid edge
may be raised and tucked down perpendicularly below the lid-edge into an
incision made for it, and held there by mattress sutures coming out of the cheek.
This procedure is satisfactory for minor cases, but for the severer forms of
cicatricial contraction the author's practice is to insert the Esser epithelial
inlay for the details of which see "Principles."

This is inserted through an incision in the conjunctiva, and carried down
for a suitable distance behind the lower lid. Great care must be taken to
distend the skin-grafted cavity by a mould. A shell with a deep edge to
go into the sulcus may be used as a retentive apparatus. Sometimes the
epithelialised cavity is maintained by black gutta-percha, which is moulded
into the shape of the socket and new cul-de-sac : in this may be cut hollows
for drainage ; but probably the best method far keeping the socket from
again contracting is to take an accurate impression and have a vulcanite
model made for insertion. Close co-operation with an expert dental surgeon
is advisable.

It is most important that the grafted sulcus be kept fully on the stretch
for a considerable period after the operation, and at no time must the pros-
thesis be removed for more than a few minutes. If this rule is followed there
\\ill come a time, which varied in our experience with different cases, Avhen
the skin-graft will cease to contract. This may take three or more months,
and seldom occurs before two months. When, however, the contraction ceases
the prosthesis may be left out for nights or even days without jeopardising
the replacement of the apparatus. It is then quite safe to insert the permanent
artificial eye.

Another cause of failure in this operation is as follows :

The skin-graft is cut badly, and is wrapped around the mould without
sufficient care being taken to have every surface covered. There are thus some
raw areas in the new pocket which ulcerate and fail to become epithelialised-

INJURIES IN THE REGION OF THE EYES 3,33

contraction and infection are then liable to supervene. Marked infection of
the socket is sometimes seen as a result of the insertion of skin-graft, but this
may be easily controlled by ordinary methods.

The method of insertion of the Esser inlay has been modified in the practice
of the Queen's Hospital, Sidcup, by Major C. W. Waldron, C.A.M.C., who first
introduced one of these inlays through the mucous membrane, as in contra-
distinction to the described Esser method, in which the inlay is inserted through
a skin incision. (This was on a lower lip case.)

There are certain advantages and disadvantages in either method. In-
sertion from the skin aspect involves a more difficult operation, external scar,
and, if infection should occur, a fistula. Should the dissection of the
cavity towards the mucous surface not be carried sufficiently near the con-
junctiva, a raw area is left when the model is removed from the conjunctival
aspect, which is liable to contraction. In one case of the author's this shut off
the epithelial cavity from the socket. On the other hand, infection is much less
liable to occur, and possible contraction is less to be feared. Incision through
the conjunctiva has the advantages of easy removal of the model, simplicity
of performance, and ready application of the retention prosthesis after removal
of the stent. There is, however, a greater probability of infection, and there
is a tendency to push scar tissue on one side rather than to excise it.

The author has not been successful in grafting mucous membrane to form
culs-de sac, but he agrees with the suggestion made to him by Colonel Sir Wm.
Lister and Captain Richard Cruise, that in making these epithelial grafts as
much conjunctiva as possible should be preserved on the free portion of the
ocular surface of the lid.

PLASTIC SURGERY

CASES 511 AND 357

One of the most successful examples of treatment of a contracted socket is Case 511,
which has been described under " Eyelids."

In Case 357 there was cicatricial contraction in both the upper and lower fornices,
and the original Esser Inlay was attempted through both lids by external incision. The
upper was successful in producing a satisfactory pocket, but the lower failed in that the
cavity made for the model was too small and not sufficiently near the conjunctiva. In
addition, scar tissue was left between the model and the floor of the socket. The stent
was removed on the twelfth day. It was then found necessary to make a considerable
incision through the conjunctiva before the epithelialiscd cavity was reached. A small
epithelial external fistula also existed. The operation was a failure as regards the lower
lid. At a later date this was reoperated, after which an artificial eye could be fitted. The
appearance, however, was far from satisfactory, as there was ptosis of the lid with cversion
of the inner ciliary margin. It is quite possible, however, that the artificial eye might
have been made to look much better by further corrections of the lid-edge and an operation
for ptosis. Treatment, however, was not continued, as the socket was still suffering from
a mild chronic infection. The black gutta-percha model which retained the two grafts in
position is illustrated, showing clearly the holes drilled in it for drainage.

FIG. 677. Mould in position.

Fio. 678. Final : Failure as regards lower lid.

Flo. 079. Mould removed.

Fio. 080. Another view of mould.

INJURIES IN THE REGION OF THE EYES

335

CASE 614

The tarsal plate and inner layers of the lower lid have been destroyed. There is no
remnant of the lower sulcus, and there is also cicatricial contraction and shortage of mucous
membrane in the inner aspect of the upper cul-de-sac.

A large epithelial inlay was inserted beneath the lower lid and contracted area of the
upper. The graft was retained by the large gutta-percha model seen in fig. 682. The shape
of the model underneath the lower lid is also seen, causing the slight swelling below the socket.

Perfect epithelialisation occurred. A deep V Y operation was performed on the cheek,
which had for its object the raising of this newly formed lower cul-de-sac. The result was
moderately successful.

Operation notes :

12.8.18. Incision was made along muco-cutaneous junction of lower lid, and deepened
f in. by undercutting the skin over the infra-orbital margin. The upper lid was also freed
from the adhesion, and an impression of the freshly cut area taken in stent and covered
with Thiersch graft from left arm. Flavine packing to remainder of socket.

Result. Satisfactory. Graft maintained by prosthesis, which has been worn since
above operation.

11.10.18. Operation. A long V incision and Y suture was carried out to raise the
new lower fornix. Adjustment of upper lid at inner canthus.

Fio. 681. Loss of lower fornix.

Fio. 082. Showing prosthesis in position.

Fio. 683. Prosthesis replaced by artificial eye.

336 PLASTIC SURGERY

SUNKEN SOCKETS

The disabilities of this condition are obvious. The eye is seldom sufficiently
prominent, and the upper lid is concave. In addition, a gunshot injury most
frequently leaves a stump which very poorly imparts movement to the artificial
eye. Mule's globes sewn in at the time of the removal of the eye have, in cer-
tain ophthalmic surgeons' hands, produced satisfactory results ; but when the
socket is healed and sunken, good results may be obtained by implantation of
cartilage or fat. Fat has been used for some years. In 1915 Carlotti and
Bailleul, of Paris, described the use of cartilage. Captain J. L. Aymard described
an independent modification of this method, in 1917. The operation has stood
the test of time, and has the great natural advantage over the Mule's globe in
that it is a living tissue implantation and not a foreign body. For primary
enucleation of the eye this implant has been modified by stitching the muscles
to the cartilage globe in approximately their anatomical positions (author).
Two cases only have been done by this method, one of which was a failure,
owing to infection of the cartilage as a result of an accident in the theatre. The
next development in the attempt to produce artificial eyes that move well is
one which has its basis in the Esser method of skin-grafting. Instead of
inserting a cartilage globe into the orbital tissues between the muscles, it occurred
to the author to make an epithelialised cavity in the same situation which
should carry a deep prolongation of the artificial eye. This extension would
then be gripped by the muscles and movement transmitted to the artificial
eye. The whole process is in a state of flux, and no definite pronouncement
can be made.

Two out of three cases have been brought to a stage in which a permanent
epithelialised cavity is situated in the centre of the orbit. The development
of the artificial eye to fit the same is at the present time in the hands of the
eye-makers ; but the two cases above mentioned now wearing a special glass
eye designed for this method are amongst the following.

For the making of an epithelial-lined cavity in the orbit, incision is made
as for the cartilage operation, and a conveniently sized Mule's globe inserted
so that the conjunctiva can be re-sewn over it without tension. A very thin
'Ihicrsch graft is then wrapped around the Mule's globe. When the excess
of the graft has been snipped of! with the scissors the graft and globe are inserted
behind the conjunctiva, which is sewn up over it. This mould stays in for a
varying time. In one case it came out the next day, but in the second case
the Mule's globe was retained for five days, while in the third the Mule's globe
did not make its appearance for five weeks, when the determining factor of its

INJURIES IN THE REGION OF THE EYES 337

extrusion appeared to be an infection following the fitting of an artificial eye,
there being a slight raw area in the conjunctiva apart from the area operated.
On the extrusion of the Mule's globe, a prosthesis was inserted after an impres-
sion had been taken by a dental surgeon. In order to keep this prosthesis in
position an apparatus may be worn (see p. 204). It remains to fit an arti-
ficial eye which carries, from its posterior surface, a stalk or prolongation at
the end of which is a blob fitting snugly into the epithelial cavity. Fig. 700
shows the view of the epithelial cavity that has been produced, and it should
be noted that these cavities maintain themselves now for several days without
contraction and without the wearing of any retaining apparatus. In adapting
the artificial eye to this principle, the author is greatly indebted to Captain W.
Kelsey Fry, R.A.M.C., M.C., and Captain Gordon Johnson, and many others
of the dental and medical staffs.

In regard to the invention of an artificial eye adapted to this operation,
the author wishes to express his appreciation of the readiness which the artificial
eye-makers have shown in the experimental stage. Case notes of the two cases
and illustrations follow.

338

PLASTIC SURGERY

CASE 641

Tin's socket liad a double deficiency that of complete absence of the lower fornix
combined with a markedly sunken socket.

A double procedure was outlined : Firstly the filling of the socket by cartilage globe opera-
tion, and, secondly, an epithelial inlay to the lower lid. The cartilage operation was per-
formed lirst. as the socket was a very clean one. The stump produced by the cartilage
implantations is well seen in the figs, as a globular swelling behind the conjunctiva.

The inlay operation was performed for me by Captain T. Jackson, R.A.M.C.

Hoth operations were successful, and a clean socket carrying artificial eye, with moder-
ately good movement, has been obtained. In regard to the cartilage implantation, two
pieces were taken from the sternal end of the seventh rib, and shaped into a globe and ball,

FIG. 684. Contracted socket and loss of lower fornix. FIG. 085. After cartilage globe implant.

which wm- inserted through a horizontal incision in the conjunctiva. Interrupted catgut
was used lor the suture material.

A diagram illustrating the method of the cup-and-ball cartilage implantation is shown,
he author is not convinced that this shape of cartilage gives any better result
than a simple ovoid or globular form.

Fl'J. tixii. () admission.

INJURIES IN THE REGION OF THE EYES

339

Case No. 64lA (Lloyd). Cartilage implantation at time of enucleation.
Muscles stitched to cartilage. The cartilage prosthesis, in two pieces, cup-and-
ball method, Avas inserted through a horizontal incision at the back of the socket.
A certain amount of exposure of the cartilage followed this operation, and
some of the thread sutures which were used to tie the muscles to the cartilage
came away. The condition very rapidly cleared up without further infection.
It must be admitted, however, that when the artificial eye was fitted there
was no appreciable greater movement than would have probably been the case
had the muscles not been stitched to the socket. The projection of this eye
is exceptionally good, and until forced movements are undertaken detection
of the artifice is exceedingly difficult. Dia-
gram of the operation and picture of the
result are illustrated :

In those cases in which a partial enu-
cleation is indicated it is considered that
this cartilage implant would give as good a
cosmetic result as the Mule's globe, with a
far greater percentage of permanent success.

Many other examples of cartilage globe
have already been illustrated, viz. Cases
292, 220, 517, 307, 558A, in the previous
chapters.

FIG. 088. Showing oup-and-ball cartilage eye.

Fia. 680. Cartilage eye-implant at time of
enucleation.

FIG. 690. Final.

.'} 10

PLASTIC SURGERY

CASE 519

Wounded, 21.9.17. Admitted, 30.9.17.

Kye removed.

14.3.18. Condition. Sunken socket partial.

14.3.18. Operation. For insertion of glass ball prosthesis with epithelial covering
through horizontal incision of conjunctiva (as in and instead of cartilage globe operation).
The epithelium was sewn over the glass globe with fine catgut. Conjunctiva sewn up
completely with horsehair.

l'n>ress. At the end of five weeks very satisfactory. A small portion of the globe
lay exposed at the back of the socket and was lying in its epithelialised bed, and the move-
ment of an artificial eye fitted thereon was excellent. Three days after this fitting the
e< instant manipulation had loosened the glass globe, and, with the addition of sepsis, it was
expelled. During this period a small adhesion had been cut at the inner points. The
probable immediate reason of the extrusion was : (1) the manner in which the artificial
eye stuck by suction to the portion of the globe exposed ; and (2) the infection.

Note. The opinion of Colonel Lister was taken on this and similar procedures, and,
in his opinion, no glass globe that became exposed would ever be retained permanently.

CLASS GUOBE.
Covr.Rirsc

Km. 001. Sectional diagram to show insertion of a skin-covered glass ball.

INJURIES IN THE REGION OF THE EYES

341

FIGS. 692, 093, 694, 695, and 696. At various stages.

FIG. 697. Final.

PLASTIC SURGERY

CASE 459

Wounded, 20.9.17. Admitted, 23.9.17. Operation, 11.3.18.

Section of right eye socket to show insertion into Tenon's capsule of a Mule's globe,
surrounded by Thierseh graft, skin-surface centripetal. The skin-graft was tightly sewn
over the glass globe by fine catgut sutures. The conjunctiva was sewn up with interrupted
horse li;iir. and a shell was placed over this for protection and retention of globe.

txplanalory o f model

Qlobe

incision

A- Lye lid.
B Ocular conjunlivo
1 C Tenons Co^sule

D- Epithelial graft sur-
rounding

E -

conjunhvci
Artificial eye

F--

E-

!U .

Fio. 698. Diagrams of the operation.

INJURIES IN THE REGION OF THE EYES

343

FIG. G99. On admission.

FIG. 700. Showing epithelialised socket.

Fio. 701. Final.

344 PLASTIC SURGERY

OPERATION FOR ORBICULARIS PALSY

Another type of plastic operation which the author wishes to bring to
notice is that for the palliative treatment of paralysis of the orbicularis muscle.

The conditions complained of with this lesion are pain and lachrymation,
due to exposure of the cornea, epiphora due to the paralysis of the orbicularis,

and headache.

The author's operation is designed primarily to overcome the exposure of
the globe : the relief of pain and epiphora is bound up in this. There is, in
addition, an attempt to reproduce the lid action.

The principle involved is the provision of closure of the palpebral fissure
by means of the spring support afforded by a delicate lamina of cartilage,
operating (in the upper lid) against the pull of the levator palpebra?. Success
depends on the achievement of just so much closure as can be overcome when
the levator is put into action.

This type of operation has been done on six occasions. In all, functional
improvement has been achieved to a greater or lesser extent, and in three the
cosmetic result has been distinctly indifferent, owing to prominence of the
cartilage. In one only has the result approached the author's ideal.

In the first operation, which is graphically described in the diagram
Fig. 702, a slender strip of cartilage was divided almost throughout its length,
so that the two portions remained united at one end. It was inserted sub-
cutancously through a small incision lateral to the outer canthus, so that each
portion occupied a position subjacent to the lid-edge. The free ends of the
cartilage were sutured with catgut through another incision just mesial to the
inner canthus. This caused the flat strips to bow forward coincident with the
contour of the globe. Fixation of the graft was ensured by suture to the
periosteum at cither canthus. A difficulty now appeared. Closure had been
attained, but there had resulted a slight projection forward of the centre of the
upper lid from the globe. This was assumed to have been caused by excessive
length in the upper cartilage bow, and a small piece was therefore excised from
its centre, with the hope that sufficient spring effect would remain to secure
closure. This hope, unfortunately, was not fulfilled : the break in the con-
tinuity of the graft allowed the spring effect gradually to wane.

In the second case it was decided to over-correct the deformity at the
outset by the provision of a strong spring, which should be weakened later if
necessary.

The cartilage lamina was therefore divided so that the two portions remained
united at both ends. A complete ring was thus formed, which was inserted

INJURIES IN THE REGION OF THE EYES 345

through an incision skirting the whole of the palpcbral fissure. Suture at the
angles was very difficult, but the appearance at the end of the operation gave
great promise. The palpebral fissure remained tightly closed for some two or
three days after the operation, when the levator action began to assert itself,
the lids commencing to open slightly and to be closed by the spring.

Then a misfortune occurred, two stitches giving way at one spot, with
infection from a chronic conjunctival discharge which had been present on
admission. The continuity of the cartilage ring, however, has persisted. It
is intended later to weaken the spring by thinning the cartilage laminsc. This
should improve the cosmetic result, and should diminish the existing prominence
of the central portion of the lids.

A simpler method of spring formation was adopted on subsequent occa-
sions, a T-shaped piece of cartilage being used, with the stem inserted beneath
the periosteum of the orbital margin, and the cross-piece subjacent to the lid-
edge. The spring closure thus attained is balanced, in the upper lid, by the
action of the levator palpebrse.

Curvature of the cross-piece in conformity with the globe is ensured by
leaving the perichondrium on the aspect turned toward the globe. The
author has found that curvature always occurs with the concavity toward
the perichondrium, and he has utilised this property of grafts in several of his
operations.

PLASTIC SURGERY

CASE 740

2.12.18. Operation. Cartilage taken from right costal cartilage in usual manner.
A thin piece was then cut approximately the length of the lids. It was split in its length,
i \i < pting a small portion across one end. There were thus two rods of the cartilage attached
at one end, which were inserted through a small incision in the right outer canthus into
the upper and lower edges respectively. They were brought out at a curved incision over
the inner canthus, where they were sutured to the periosteum. A small horizontal incision
\\as made in the upper lid half-way across to facilitate the manipulation. The cartilage
at the outer canthus, where the two rods were attached, was likewise sewn down to the
periosteum.

The effect was now to obtain a strong and complete closure of the palpebral fissure.
However, the upper rod was too long and the lid was not in apposition with the globe.
Instead of reopening the inner canthus incision, where the fixation of the rods had been
difficult, a small portion was excised from the middle of the rod of the upper lid. On tying
the rod together with catgut it was found that too much had been removed, and, had they
been permanently sutured together, the lower rod would have bowed the lower lid awav
from the globe. It was therefore left unsutured in the hope that the spring of the cartilage
would be sufficient to give a partial closure to the fissure.

Early result. This was apparently accomplished.

Later result. No improvement. Operation to be re-done.

"-V.

Fios. 702, 703, and 704. For description see text.

INJURIES IN THE REGION OF THE EYES 347

BURNS OF THE FACE, INCLUDING THE EYELIDS

SOME of these cases are among the most terrible with which the plastic surgeon
is confronted. By a counterbalancing fortune many of them are amenable
to surgical treatment to a remarkable extent.

Of the cases of facial burns that have come to me for treatment all had
an involvement of the eyelids. This is frequently the most important element
of the disfigurement and disability. In other cases, it is the only disability
remaining, while in the more severe cases the nose is burned to the bone, the
mouth is contracted, and the whole of the facial skin has been replaced by
epithelialised scar tissue.

The main causes for burns, apart from the ordinary household accidents,
are, in their order of frequency and occurrence, as follows :

(1) Cordite Burns. These occur in the burning of munition dumps, from
backfires, or premature bursts, and from magazine or other fire in naval actions.

The recipient of this class of burn has usually the power to run away from
the fire, consequently the area of the face burned is not constant. In the more
severe forms they resemble the airman's burn, except that, there being no
protecting leather helmet, there is no line of demarcation. Sometimes the
upper part of the face receives the full brunt, and, in others, the lower part.
Whether the neck is involved depends on the clothing that is worn at the time
of the injury ; thus, an ordinary seaman, whose neck is exposed, has this area
burnt in addition to the face, while a muffler and a tunic will afford much
protection to the area below the chin.

In contradistinction to the airman, whose ears are seldom burnt by fire,
the greater majority of cordite burns present a lesion of the pinna.

(2) Petrol Burns. These are caused through a plane catching fire in the
air or in a crash. The unfortunate pilot or observer usually receives ghastly
burns of the face whilst strapped to his seat. Should he survive, a typical
airman's burn results, which may be described as being limited by the airman's
helmet ; and usually one finds a definite area of healthy skin commencing from
where the helmet protects the face and head. In one case, the burned area
stopped just below the chin, where the helmet commenced, but farther down
the neck two kcloidal scars occurred where the buckles of the strap had become
red-hot. The extraordinary protection which this leather helmet affords the
airman leads one to hope that some protecting device against such terrible
calamities may be devised. The airman's ears usually escape destruction, even
in severe burns.

(3) Acid Burns. These are usually the result of a factory accident, some
caustic, such as nitric acid or sulphuric acid, being splashed on. to the face.

348 PLASTIC SURGERY

(4) Burns from Flame-throrver.One case, whose origin is a little obscure,
said to be due to a German flame-thrower, is the only representative of this
class of injury which has come under the author's care.

(5) Electric Burns. One case of electric burn has been under the author's
observation.

In regard to treatment, this should be divided into early, intermediate,
and plastic.

In the early treatment the War Office No. 7, substitute for ambrine, would
appear to give as good results as any. Picric and vaseline dressings would not
appear to give results markedly inferior to paraffin. McLeod recommends the
use of stcarate of zinc for the avoidance of limpet-like crusts.

The rationale of all this treatment would appear to be the non-disturbance
of the granulating area and the protection of the wound from the air.

There is no question that frequent removal of dressings which adhere to
the surface is distinctly disadvantageous.

Early operative treatment is indicated in the form of skin-grafting to the
eyelids when the sight is in danger, or when, the shock of the burn having passed,
a definite and clean raw area is presented ; but no experience can be quoted in
support of this opinion.

In regard to the intermediate treatment, when the epithelium is regenerated,
graduated massage is of great value. Insufficient experience prevents a decided
opinion on the value of electro-therapeutic measures at this stage, but radiant
lic-at and ionisation may be carefully employed.

At what stage should plastic operations be commenced ? This is a difficult
question to answer, as the time appears to vary in different cases. The author
is not sure that any plastic operation should be commenced until all contraction
has ceased and the scars are commencing to become white. This is, however,
apart from any consideration of plastics on the eyelids, which may have to be
undertaken for the protection of the globe on short notice at any stage of the
treatment.

Another consideration which favours delay is the difficulty in the earlier
stages of deciding how much regeneration of the epithelium is going to occur,
and consequently how much of the face it is necessary to replace by healthier
skin.

The third, or plastic, stage having arrived, a further consideration must
be taken into account. Will the scar so materially improve under X-ray or
radium treatment that eventually operation is only indicated for parts such as
eyelids, eyebrows, tip of the nose, or angle of the mouth ? The author feels
that for severer burns the complete replacement of the scar tissue by healthy

INJURIES IN THE REGION OF THE EYES 349

skin gives a better cosmetic result, and that the trend of plastic surgery to-day
is towards a more radical procedure. Each case, however, must be considered
by itself, and the general state of the patient, the physical and mental condition,
must be weighed in the balance. There is no doubt that in one very severe
burn the author subjected the patient to too great a shock.

THE OPERATIVE TREATMENT OF BURNS

As has been pointed out, the most important and constant factor in the
facial burn is the cicatricial ectropion of the eyelids. In only one of the following
cases have the eyelids escaped.

For this disfiguring disability the author's operation has completely super-
seded previous procedures. In only two of the series of ectropion have plastic
flaps been used, in all the others the author's method, based on the Esser skin-
graft, has been employed. A typical case of ectropion from fire results in
the destruction of the skin of the eyelid, leaving the tarsal plate and musculature
intact. In the worst cases the latter are also involved, and the whole of the
thickness, even of the lid, may be destroyed. In two of our cases the destruction
went farther and the globe was destroyed.

The operation for the typical upper eyelid ectropion or epithelial outlay
is as follows :

Incision is made just above the ciliary margin, extending right across
the involved area, usually from canthus to canthus. The lower flap of skin
is very slightly undermined, to give a free edge. The upper flap is freely under-
mined superficially to the musculature, until the lid-edge drops over the globe
and easily reaches the lower lid. A little further undercutting is continued,
especially laterally.

Some sterilised dental modelling composition is now moulded into the
wound and allowed to set. It is reduced to just such a size as to allow skin
approximation over it. Its shape is usually one that can be compared with
the scaphoid bone of the carpus, minus its tubercle.

The anterior surface of the arm is now prepared for skin-graft by thoroughly
rubbing with aether all over until it is pink, and an evenly cut thin Thiersch
graft taken of such a size as can be Avrapped round the mould in one piece.
The skin-graft has to be placed on the mould with its raw surface outwards.
Excess of graft is cut off with sharp scissors.

In the process of wrapping the graft round the mould the centre of the
graft is laid on the back surface, and smoothed out over the borders towards
the anterior surface.

PLASTIC SURGERY

inci&ion,

JUST ffBOVC CIIMKV OORDIR,

TWIERSCH GRAFT in POSITION

SHOWING SUTURES THROUGH

CVtUO AMD THIERSCM GRAFT

IMCIMON ALONG LIME or SUTURES

FIG. 705. Stages in the epithelial outlay.

The graft and
mould arc now taken
in rat-tooth forceps,
the skin smoothed out
over the anterior sur-
face, and the excess of

HOLLOW, SHOWING RflW RE ].. m . n f4- f, ,, f n f f

TO RECCIVt THIERSCM ORI"T SKin-gltlll 11 II.

With another pair of
rat-tooth forceps the
grip is changed and
the first pair of forceps
removed. While this
process, which is some-
what tricky, is being
carried out, the assis-
tant should pass two
horsehair sutures in
readiness to be tied
from one skin edge to
the other. The loops
of these stitches are
held out of the way,
the mould and graft
are slowly lowered in-
to position, and the
sutures tightened be-
fore the forceps are
removed. If after one
suture is tightened, the
forceps are removed,
the mould, with its
graft, is very liable to
slip out of the wound.
The further suturing
of the wound is carried
out with horsehair, and
it is the usual practice,
in passing the needle,
to pick up the graft,
so that it is drawn

UPPIR no LOWER Eoccs or
incision aurunio own STENT

EYELID LOWERED SHOWING
OUTLINE OF THIE^SCH vCRAFT

INJURIES IN THE REGION OF THE EYES 351

between the raw skin edges. The knots are cut short after being securely tied,
and the wound painted with tincture of benzoin.

The eyelid now assumes a position of more marked ectropion than prior
to the operation, and a protective covering to the exposed conjunctiva is
necessary.

After Treatment. The eye is kept clean by boric lotions and the wound
kept free of scabs, the mould being left in position for some ten to twelve days.
As a rule, by the end of this time part of the mould is already beginning to be
extruded through the original incision, and its complete removal is carried out
by following along the incision line with a thin pair of scissors. Care must
be taken to reopen the incision right to its full limit otherwise the ends will
be pocketed. The eyelid now drops to below its normal position, and the skin-
graft is invariably to be found completely successful ; there are only some
very small raw edges, due to the reopening of the incision, which remain to
epithelialise. By the manoeuvre of picking up the skin-graft with the needle
at the time of suture, the amount of this raw edge is very materially diminished.

The appearance is somewhat bizarre in the first instance, but the great
hollow produced by the mould rapidly fills and. smooths out. In the upper
lid no corrective operations are usually necessary, but in the lower lid the lower
margin of the graft where it joins the cheek is usually very thickened and con-
spicuous, and it is usually found necessary to excise this ridge under local
anaesthesia at a later date.

Common Errors of the Operation. (1) If done before contraction has ceased,
i.e. too soon after the injury, the continuance of the fibrotic change in the tissues
beneath the graft will cause a shrinkage of it.

(2) The area grafted is frequently insufficiently wide.

(3) If pieces of the dental composition are chipped off by instruments, as
when the mould is trimmed with a knife instead of being moulded out while
hot, or when the mould is handled with rat-tooth forceps which are subsequently
introduced into the wound, little pieces or chips of the composition get into
the wound, and act as a source of irritation or infection.

(4) If the graft is not carefully wrapped around the whole of the mould
some of the latter comes in contact with the raw surface of the wound, and that
part is found not to be grafted.

(5) An excess of graft tends towards the formation of epithelial debris,
and there is more chance of an infective process commencing. Infection,
however, is very rare.

The lower lid is treated in the same manner, but the epicanthus condition,
which is frequently present, requires a separate graft which cannot be buried.
For this a piece of modelling composition is merely held down by stitches

:1 . v _> PLASTIC SURGERY

retaining the graft in firm apposition, after excision of the scar band causing
the epieantltus. The results are very nearly perfect as far as the upper eyelid
is concerned, both aesthetically and functionally. Those of the lower lid are
equally successful from a functional point of view, but the appearance is not
so neat as in the case of the upper lid. Where, in addition to the eyelid
burn, there is a necessity to replace the whole of the skin of the face, the
author's tube-pedicle chest-flap methods are indicated.

The principles of this operation arc as follows :

The area of the face which is to be substituted by chest skin is accurately
measured and mapped out on the upper part of the chest. To this area are
designed long neck pedicles usually two and a half to three inches in breadth,
and left attached at both ends. The first stage consists of raising the
pedicles and tubing them that is to say, they are lifted free of the neck and
sewn skin-edge to skin-edge, into a tube. The pedicles may be single or
double, according to the amount of facial replacement necessary. The raw
area of the neck from which the pedicles have been lifted is usually covered
in by approximation of the skin edges beneath the tube.

The second stage consists in raising the flap of skin with its pedicle or
pedicles. After the excision of the burned area of the face the flap is passed
up over the chin and sutured into the raw area, the necessary cuts being made
in it for mouth, nose, or eyelid apertures. As a result of experience, it is
found better to include part of the flap in the tubing, and, after healing
has occurred, following the second stage, the pedicle is cut from its original
blood supply, reopened, and spread over the remaining portion of the face.
For example, it is possible to make the nose portion of the replacement
with an extra portion of the tube pedicle.

No pronouncement can be made as to the length and breadth of the pedicle,
or the size of the flap that can be utilised with success ; but in a patient already
severely shocked the raw area on the chest is an additional strain, and in one
case of the author's, where the flap went gangrenous on the face, the double
raw areas on the face and chest were so severe that the patient succumbed
three weeks after operation. Perhaps also the mental effect of the failure
contributed to the poor fellow's demise. In a later case of an airman's burn,
the procedure has been modified by the introduction of a new principle that
of shifting the upper end of the tube pedicle first. The various steps in these
large laeial replacements are reviewed on page 372. The illustrative cases are
arranged roughly in chronological order as they presented themselves for treat-
ment. This is done to indicate the process of the evolution of the treatment to
the present, dat e. :i nd i t. is felt that if they had been presented according to their type
of injury misunderstanding of certain of the failures might possibly eventuate.

INJURIES IN THE REGION OF THE EYES

.'353

FIGS. 706 and 707. Before treatment : showing ectropion and epicanthus condition.

FIG. 708. Immediately after removal of stents.

Illustrative cases :

CASE 645

A burn as a result of this officer's machine
catching fire in action. Although the whole
face has been burnt the skin has regenerated
sufficiently satisfactorily, but gives one the im-
pression of a face that has suffered from small-
pox. The eyelids, however, were the seat of
ectropion, complicated by much scar tissue in
the inner canthus region, simulating epicanthus.

Skin-grafts by the " outlay " method were
applied to all four lids at the same operation, and
the closure obtained therefrom is well seen in the
photograph taken immediately after the removal
of the moulds. Later, it will be observed that the
epicanthus is well marked on the left side espe-
cially ; this was dealt with by further skin-graft,
held in position by stent in the inner canthus
region ; that on the right was treated by ex-
cision, which, in this case, appeared to be
sufficient.

In regard to the cure of epicanthus by this
skin-grafting method where this is combined with
a lower lid ectropion, I think it is the best pro-
cedure to carry the graft of the lower lid round
the canthus to the upper lid.

Fia. 709. Same stage later ; epicanthus still present.

FiQ. 710. After further graft to cure epicanthus.
Eyes closed.

PLASTIC SURGERY

CASE 124

The causative agent of this burn, resulting in ectropkm of the upper and lower lids,

Milplmrir acid, which reached the eyelids after the bursting of a bottle containing it
in a munition factory.

The method of treatment adopted was that of plastic flaps, and three operations were
required before a sufficiently satisfactory result was obtained.

The first operation, as illustrated in the diagram, is somewhat wrong in principle as
far as the upper lid is concerned, as the gain of tissue and resuture of flaps was not sufficiently
definite. Similarly, the "V Y " operation at this first stage was insufficient to cure the
lower lid condition. Fig. 712 represents the loss of tissue in the upper lid, combined with
marked ectropion of the lower. All^the eyebrow had been destroyed, while the next fig., 713,
shows the result of the first "operation.

Following this operation a similar flap was let in beneath the lower lid from the cheek,
with further, but still inadequate, improvement. This was done by my colleague, Captain
\Yilliains.

A month later the lower lid was further improved by a swinging flap, as illustrated in
the diagram.

The total result was quite satisfactory, but in view of the later results, a quicker and
better result would have been obtained by the " epithelial outlay " method.

To complete this case an eyebrow should be grafted into position. A pencilled-in
eyebrow is illustrated.

Fio. 71 1.- Diagrams of the three operations (see text).

INJURIES IN THE REGION OF THE EYES

355

Fio. 712. Healed condition.

Fio. 713. After first plastic.

Fio. 714. After second plastic.

Fio. 715. After third plastic. (The left eyebrow
is pencilled.)

356 PLASTIC SURGERY

CASE 338 '

This poor sailor was rendered hideously repulsive and well-nigh incapacitated by terrible
burns received in the battle of Jutland.

How a man can survive such an appalling burn is difficult to imagine, until one has
met one of these survivors from fire, and realised the unquenchable optimism which carries
them through almost anything.

In addition to the total facial burn viz. destruction of the nose, lips, eyelids (not the
lid-edges) the ears and neck were burnt ; and the hands were contracted into frightful

deformities.

I had only seen one case comparable with this, and that had not yet come to the plastic
stage ; and it required very considerable moral courage to attempt an operation such as
could in any way radically cure the condition.

The process of thought on the problem led one to decide on a double-pcdiclcd chest-
flap, the pedicles to be tubed to prevent their being infected or exposed, to leave attached
to these pedicles as large a chest-flap as was deemed viable, and then to place this large
flap on to the face, excising the area covered by it.

It was hoped to swing the pedicles, at a second stage, up to the eye region for the cure
of the ectropion ; but, as will be seen by the progress of the case, a much better eyelid
operation was, in the meantime, evolved (see Case 152), and this left the pedicles available
for other purposes.

The big flap was split at the first operation, to encircle the mouth, the lower border
of this incision was sutured to the mucous membrane of the lower lip, while the upper border
was carried round over the tip of the nose ; but the upper lip was not replaced, as the scar
tissue was not so marked there. In order to get the flap free from tension, it was necessary
to keep the neck flexed, and an apparatus, in plaster, was fixed behind the patient's head,
so that this position might be kept.

The result was very satisfactory in every way, except in that portion of the flap which
went over the sharp bridge of the nose : at this spot the skin was at its greatest tension,
and any movement of the head and neck tended to tear the stitches which retained the flap
on the nose. It was soon found that this small part of the flap began to slide down off the
nose, and this movement affected its blood supply and gangrene supervened. No other un-
toward result occurred.

In regard to the raw area of the chest no attempt at a closure was made, and the main
line of treatment carried out for this area was the use of paraffin No. 7. At one stage hot
fomentations were also applied to clean the surface.

No grafting from the patient was attempted, but three small grafts from another case
were laid on the granulations, without success.

The next stage consisted in the severance of the left pedicle ; this was done, under
novocaine, thirteen days after the operation. The right pedicle was severed about a fortnight
later.

Three months' rest was given, and then the condition was as shown in the illustration.
Attached to the cheek on each side were two loose tubed pedicles of skin, and they
w< -re available for parts other than the eyelids, owing to the development, in the meantime,
of the " outlay " method. Therefore, at this operation, the left pedicle was partly detached
from below until it was swung round to form a flap of skin sufficient for rhinoplasty, the
necessary lining being provided by turning some of the epithclialised scar tissue inwards.
At the same operation both upper eyelids were treated by epithelial " outlays " in the
manner described at the commencement of this section.

Three months later epithelial " outlays " were applied to both lower lids, the secondary

pedicle of the rhinoplasty divided and trimmed, and the right original pedicle opened out

and spread over the right cheek, where it was sewn after the necessary excision of sear tissue.

A long rest was then given to the face, but in the interval an operation was performed

on the hand.

Four months after the last face operation, cartilage from another man was inserted

INJURIES IN THE REGION OF THE EYES

357

FIG. 716. Healed condition.

FIG. 717. Flap swung to face.

- %

*^5r *^

FIG. 718. Left pedicle divided.

FIG. 719. Both pedicles divided.

358

PLASTIC SURGERY

Fio. 720. Left pedicle swung up to new
attachment near nose.

Fio. 721. Lower end of pedicle
used in remaking of nose.

FIG. 722. After epithelial outlay to upper lids and rhinoplasty.
Not* lymph-oedema of nose at this stage.

_VtW-|U

Before treatment. Right eye. Before treatment. Left eye.

Flos. 723 and 724. Showing condition of ectropion.

into the bridge of the
nose to give more defini-
tion and prominence,
while trimming and al-
terations were made in
the right ala. At the
same operation two
whole-thickness grafts
from the scalp were taken
to make eyebrows. The
author has found that a
free graft from the edge
of the hairy scalp above
and behind the ear gives
a satisfactory direction of
hairs for an eyebrow
graft. These grafts took
satisfactorily.

Operation notes :

Injury, May 1916.

3.10.17. Operation.
Masonic-collar flap with
double-tubed pedicles
raised from the chest and
grafted on to the face
(author's method). See
diagram.

16. 10. 17. Left
pedicle divided (novo-
caine).

1 . 11 . 17. Right
pedicle divided.

19.2.18. (1) Left
pedicle undercut and
switched to nose. (2)
Epithelial " outlay ' to
both upper eyelids for
ectropion, by author's
method.

30 . 5 . 18. (1) Epi-
thelial " outlay " to both
lower lids. (2) Trimming
of nose pedicle. (3) The
original right pedicle
spread across the right
cheek towards the ear.

6.3.19. (1) Carti-
lage (homologous) to
nose. (2) Trimming of
right ala. (3) Whole-
thickness (Wolfe) grofts
from scaly to form eye-
brows.

INJURIES IN THE REGION OF THE EYES 359

Right eye open. Left eye open.

FIG. 725. Right eye soon after graft.
The edges of graft are too abrupt.

Closed. Closed.

FIGS. 726, 727, 728, and 729. After excision of edges of grafts.

FIGS. 730 and 731. Present condition. Note the eyebrows (free grafts).

3(JO PLASTIC SURGERY

CASE 864

This naval warrant officer was very severely burned in the battle of Jutland.

A most interesting record was presented to me by the patient in the form of a photograph

taken of his face soon after the injury. From this the whole face would appear to have

been charred, and it is indeed remarkable to note the wonderful progress that had been

obtained during the healing process. Of what treatment he received, and by whom, the

author is ignorant The condition on admission is shown in the second and third pictures.

A very marked cicatricial ectropion of all four lids was the most disfiguring feature of

the case. In addition, the upper part of the face, from the level of the nose to the forehead,

was a mass of white, waxy-looking scar tissue. This waxy appearance tended to accentuate

the glaring redness of the ectropion.

It was decided to carry out a complete replacement of the upper half of the face,
and for that purpose a chest-flap, with double pedicles, was designed.

In order to avoid gangrene trouble in the flap, it was thought advisable to tube the
pedicles and partly undermine the flap as a preliminary stage, in contradistinction to the
previous case, in which the pedicles were tubed at the time of operation. As the flap had
to be carried on to the upper part of the face the base of the pedicle had to be designed at
a higher level on the neck, and it was in consequence not very broad, being only about
2j inches.

An undoubted mistake was made at this first stage in that an attempt was made to
stretch the part of the flap which was going to fit over the prominence of the nose. Thus,
the central portion of the flap proper was undermined, and a piece of stent (modelling
composition) was moulded into the form of the nose on its anterior aspect, and to fit the
chest on its posterior.

On this back surface Thiersch grafts were laid, so that the raw area, caused by the
elevation of the flap, might be partly covered in by epithelium. No skin-graft was laid
over the anterior aspect of the mould, and consequently infection and irritation of the
under surface of the flap followed.

It thus happened that when the flap was raised finally from the chest and sown into
the appropriate area of the face a very marked infection of the whole area occurred, and
this, obviously, was entirely due to the attempt above described to stretch the flap prior
to it being put on the face. This chest-flap was incised in two places on each side, one slit
for the palpebral fissure and another through which the remnants of the eyebrows were
brought. The flap, with its double pedicle, in the suppurating stage, is well illustrated
by the photograph, as are the small areas of the flap which failed to live.

After the return of the pedicles to the neck, which process healed by first intention,
considerable time was allowed to elapse before further treatment was undertaken, but
during the interim massage was administered.

It is a very interesting fact that this patient could be made to blush into his new flap
at the time when the pedicles had been just returned to the neck. Since then, not only
has the power of blushing continued, but the natural lines of the face became at a very
early date evident, and an accuracy of sensation has fully developed.

Corrective operations, for enlarging the palpebral fissure and for excision of excess
tissue, were subsequently done ; but it became apparent that the flap, as grafted, had not
entirely cured the ectropion.

Hy this time the author's "epithelial outlay" operation had been fully established,

kin-grafts in the areas indicated in the diagram were successfully carried out.
\N ith the addition of artificial eyebrows a presentable appearance was obtained, while
the ectropion was cured.

The latest news from this patient, who has returned to duty, is that he has been passed
by the naval authorities medically fit for service.

INJURIES IN THE REGION OF THE EYES

861

Fio. 732. Soon after facial burn.

Flo. 733. On admission. Marked ectropion, and
scarring of forehead.

Operation notes of this case :

12.11.17. Condition. Severe cordite burns, face now healed, affecting mostly upper
part of the face. Loss of both lower lids. Loss of both upper lids, with marked ectropion.
Remains of the edge of the lids, and some eyelashes, are present. Forehead and eyebrows
burnt and scarred. Slight remnant of each eyebrow remains. Nose, fleshy part, burnt
off, and a thin white ivory scar remains. A similar white scarring below and external to
each eye.

12.11.17. Operation. Chest-flap, fig. 734.

Note. Central dotted portion was the area raised by the stent mould, the under
surface of which carried skin-graft for the chest- wall.

18.11.17. The stent holding in the graft caused trouble, too much tension over
the tip of nose, stitches had to be cut, collection of pus, and temperature until removal of
stent.

30.11.17. Operation (second stage). Transference of flap to face after excision of all
the epithelialised scar tissue, from the level of the tip of the nose to \ in. above the eyebrows.
The blood supply of this flap was noted to be fairly satisfactory at the operation.

13.12.17. Progress. Very considerable suppuration followed operation. The flap
was almost floating in pus at one time, and drainage tubes had been inserted at several
places. Small area of gangrene occurred over the tip of the nose and above the eyebrows.

8.1.18. Operation (third stage). Pedicles returned to the neck. A free blush into the
new flap is to be observed.

9.5.18. Operation. Palpebral fissures widened. Excision of scar tissue at margin
of flap.

24.7.18. Operation. Three epithelial "outlays." See diagram.

302

PLASTIC SURGERY

FIGS. 734 and 735. To show tubing of pedicles and undercutting of flap.

Fio. 736. Flap in suppurating stage (see text).

737. Pedicles returned. Ectropion persisting.

INJURIES IN THE REGION OF THE EYES

363

FIG. 738. Showing areas treated by outlay.

FIG. 739. On discharge. Ectropion relieved.

364 PLASTIC SURGERY

CASE 388

There was a very pathetic sequel to this most terrible case, in that the patient after
having survived the ordeal of the burn, lived and regained a certain amount of strength
twi-nty months after the injury, died as a late result of a plastic operation.

He was admitted to my care fifteen months after the injury. The picture of the con-
dition shows the injury remarkably well. The colour of the scar tissue, which was an ugly
red made the appearance more ghastly than the illustration portrays. In addition to the
left eye being burned and to all the other destruction in evidence, the right eye was prac-
ticallv blind, as a result of staphyloma of the cornea.

He had received most painstaking and careful treatment prior to his admission to my
department ; included amongst other things, a skin-graft to the upper lid had been done,
which undoubtedly saved the remaining sight.

In view of the success of the two cases of burns described before this one, it was decided
to replace the whole skin of the face by a chest-flap. The flap was designed larger than
those for the two previous cases, and was of sufficient size to cover the whole face. As a
preliminary, the neck pedicles were tubed. At this stage also incisions were made into the
area of ski'n which was going to form the face, and they represented the slits necessary to
make the mouth, nostrils, and palpebral fissures. These incisions are distinguishable as
scars in the illustration, fig. 742, and it should be noted that they became keloidal scars and
did not heal up at all quickly ; they were sewn up with horsehair.

After the pedicles had been made, a rest of two and a half months was given, as the
patient was obviously slow in recovery, both generally and locally, after which it had to be
decided whether to give this unfortunate airman a further year's rest or whether to carry
on with the procedure, knowing that the latter might not succeed.

The patient had got used to a considerable amount of morphia and a certain amount
of stimulants since the time of injury, which was certainly derogatory as far as his treatment
was concerned. Having pinned his faith on the result of the forthcoming operation, he
was bitterly disappointed and exceedingly depressed at the thought of having to wait another
long period, and it was feared that he would not wait so long.

Owing to the generally poor healing powers of the patient, it was decided to add two
more pedicles to the flap, the design of which is visible in the illustrations. The operation
was duly carried out, and was an exceedingly tedious one. Skin to cover the raw area of
the chest was taken from a volunteer, which part of the operation was very kindly
undertaken for me by Lieutenant-Colonel H. S. Newland, D.S.O., A.A.M.C.

The appearance at the end of the operation was pleasing, and the blood supply to the
flap seemed sufficient to ensure its persistence. When the patient had recovered from the
shock of the operation and the long ana>sthetic there was, quite obviously, good blood
supply in the flap. Next day, however, the patient was considerably collapsed, and the
flap itself suffered in the general depression of circulation, and in thirty-six hours became
blue. From then onwards there was a steady progress of the gangrene, which went from
dry to moist over all the flap, except a small portion of each pedicle. The skin-graft to
the chest failed to take, and despite the most unremitting care of the sister in charge, and
Captain R. Montgomery, R.A.M.C., the patient gradually sank and died twenty-four days
after the operation. Both the chest area and that of the denuded face became infected,
and towards the end mctastatic abscesses occurred in various regions.

In reviewing the case, the attempt to reconstruct the whole face is a procedure which
is obviously justifiable, and it would, in a more reposed patient, have succeeded. It
is possible that, had the author taken a very firm attitude, and could he have persuaded
the patient to wait a year, the operation, as planned, would have had more chance of success.
The author is convinced that the operation should have been done in piecemeal perhaps
that one <|n;irtrr only of the face should have been done at a time. By this means a very
presentable result mi^ht have been gained ; but it obviously would not have been as good
as the single replacement method, and the author feels that his desire to obtain a perfect
result somewhat over-rode his surgical judgment of the general condition of the patient.

INJURIES IN THE REGION OF THE EYES

365

The operation took much longer than was anticipated, the shock was greater, and with the
failure of the skin to take on the chest and of the flap to live on the face, the severity of
the operation was enormously increased. One could have wished that this brave fellow
had had a happier death.

Fid. 740. Healed condition.

FIG. 741. First pair of pedicles tubed.

FIG. 742. Flap and second pair of pedicles out-
lined. Note keloidal condition of scars.

FIG. 743. Flap swung to face. (See text.)

3(JG

PLASTIC SURGERY

CASE 152

This gunner received, on 22.10.16, a cordite burn, and was admitted three months
later, when the condition was still unhealed.

After another two months, the first plastic was performed, and this consisted in the
excision of scar tissue across the root of the nose anil the left inner canthus region ; the
raw area thereby caused being filled in by two flaps. The main one was brought down
from the forehead and laid across the root of the nose and left inner canthus region : the
subsidiary flap on the right side was made to advance to complete the right aspect of the
nose.

The result of this operation was unsatisfactory, as an acute infection was lit up by
the excision of the scar and no primary union occurred.

Next, a whole-thickness free graft (Wolfe) was attempted in the right lower lid, below
the eanthus ; but there was no definite evidence that any benefit had accrued.

Before the next stage the author had been doing the Esser inlay for entropic conditions,
and it occurred to him that the process might be reversed and the principle applied to ectropic
conditions. To distinguish the latter from the Esser inlay the name " epithelial outlay "
was given it ; and the operation is described on p. 350.

As regards the upper lid, the result was all that could be wished, but a certain amount
of infection of the lower left lid occurred, and the area grafted has not blended with the
surrounding tissues.

Operation notes :

Operation. Excision of scar and flap operation as per diagram.

4.6.17. Operation. For restoration of right lower eyelid. Excision of scar and
replacement of lid to normal level. A triangular piece of skin from the chest, denuded of
fat (size, roughly, f in. each side), was inserted and stitched in.

23.11.17. Result of free graft was problematical. Slight ectropion of lid.

General condition. Great improvement in skin under massage, still ectropion of lower
lids and marked 'shortening of left upper lid.

23.11.17. Operation. -To cure ectropion condition all three lids by reverse epithelial
inlay method, or epithelial outlay.

1. Incision over left upper lid widened and deepened, until lid dropped into position.
Cavity deepened further, and an impression of this cavity taken in stent, covered with
Thiersch graft, and sewn up.

2 and 3. Similar procedure in both lower lids inner ocular angles. External in-
cision reopened and stent removed.
This allowed the upper lid to fall
down into position.

Later : The left lower lid stent
was extruded and a little suppur-
ation occurred. The right side was
taken out on tenth day.

Fio. 744. Excision of scar and plastic

Fio. 745. AVolfe graft to relieve ectropion right
lower lid.

INJURIES IN THE REGION OF THE EYES 367

Fio. 746. On admission.

FIG. 747. After first plastic.

FIG 748. After outlays.

FIG. 749. Final : Showing relief of ectropion.

308 PLASTIC SURGERY

CASE 513

This is an excellent example of the use of the tube-pedicle flap to replace a portion of
the face.

The burn, on this occasion, was due to the premature burst of a shell in action.

Apart from the eyelids, which were the seat of cicatricial ectropion, the whole face
and neck were generally burnt, but had recovered with slight disfigurement of the skin,
except in the region along the line of the mandible ; here was marked, dense, keloidal scar
extending from one ear to the other along the mandibular contour, considerably more
marked on the left.

The first and most important part of the treatment consisted in providing the cornea
with a covering, and, in order to cure the ectropion, epithelial outlays were carried out for
both upper lids. At the same time the right mandibular scar was excised, and the skin
merely approximated.

The early results of the epithelial graft of the eyelids were satisfactory, but a certain
amount of contraction subsequently occurred, not sufficient, however, to cause discomfort
to the patient.

At the next stage, undertaken five months later, a flap was designed on the left side
with the base in the posterior triangle of the neck. Parallel cuts were carried downwards
ami inwards over the anterior chest wall, separated by an interval of 3| inches, the width
of the flap.

The flap was raised and sewn into a tube in the usual manner, by sewing skin edge
to edge on its under surface. The area from which the flap was raised was covered in by
widely undercutting the skin margin and approximating them beneath the tube. The
result was satisfactory.

It is to be noted that in order to get the closure more easily, the skin over the posterior
triangle was advanced up to the clavicle and held there by deep catgut sutures passed
through the periosteum of that bone. Twenty-one days later the lower end of the flap
was detached, partially opened, and grafted into the chin area. The necessary amount of
scar tissue was excised to receive it.

Two months afterwards the upper end of the tube flap was detached, the rest of the
scar tissue extending up to the ear was excised, the tube opened, and the flap spread across
the raw area. The upper extremity of the flap was split, one portion going over the front
of the ear and one behind. This was done in order to free the pinna, which was involved
in the general scar contraction. It should be noted that the blood supply to this flap was
perfectly satisfactory, both at the first and second shifts, but of the two the second shift
appeared more safe than the first. If this indication is true, it would indicate that the
new blood supply to the flap from the chin region was of a more vigorous nature than that
which it received from its original base in the neck. As a corollary, if this hypothesis is
true, the radical procedure of shifting the base of the pedicle first would be indicated. This
has, in a later ease of the author's, been undertaken, but there are not sufficient data to
establish the principle.

Great relief lias been experienced by this patient in the additional freedom of movement
by the excision of the scar.

*._'. is. ()/iiriiti<m. Epithelial outlays, both upper eyelids for ectropion and excision
of riylit mandibular scar extending up as'far as the tip.

AY.s ult. Almost, complete closure of palpebral fissure. Some subsequent retraction
liiis occurred, caused by amount of scar tissue present.
1 s . .' . 1 8 . O/in-dtion. Removal of stcnt.

25.7. 18. ()/>, ml ion. A flap was prepared from left side of neck and left pectoral region

for transference tot he mandibular region to replace scar tissue. Width of flap 3| in., parallel

ut, the outer cut emitiimcd farther down the chest than the inner base of flap, in posterior

triangle of left neck at the anterior border of the trapezius. After undercutting this flap

it was \, is can fully tubed.

INJURIES IN THE REGION OF THE EYES

369

.r : ii m / j.m

k. ^^^^^^^^^^^^ ' J^^H

?V -~a /

Fios. 750 and 751. On admission.

Fio. 752. Showing area excised and preparation of tube pedicle.

370

PLASTIC SURGERY

Hy extensive undercutting of the remaining skin and suitable advancements, it was
found possible to get a complete closure under the pedicle. (Note that a special advance-
ment of the upper end to the clavicle helped this considerably.) First of all a number of
deep relaxation catgut sutures were inserted. Two of these united the trapezius and sterno-
mastoid muscle to the periosteum of the clavicle to obliterate the usual supra-clavicular
hollow. Relaxation sutures and buttons were also used. Drainage tube from clavicle
region. Result satisfactory. Primary union.

3.8.18. To transplant the pedicle flap to take the place of the scar tissue on neck
and chin. The scars on neck and chin were excised, as shown in photograph. The
skin retracted about 1 in. The portion of skin marked " A " was retained, freed, and
swung to the left with its base attached upwards. The pedicle of the tube-flap was separ-
ated at its extremity, and its outer half opened up and sutured to the raw area made by
the excision of the scar. At the inner canthus of each eye a small plastic was performed
to correct the tendency to almond eyes.

Fio. 753. Pedicle tubed.

Fio. 754. Chest-flap swung to chin.

INJURIES IN THE REGION OF THE EYES

371

Side view.

Front view.
Fios. 755 and 756. After plastic.

372 PLASTIC SURGERY

CASE 1002

Case 1002 was almost a typical " airman's burn "that is to say, serious damage
is limited by the airman's helmet to the face ; the upper half of forehead, and the ears and
neighbouring strip of cheek escape. There was, in addition, a less serious bum of the
fronto-parietal region.

The resulting keloidal scar had led to severe ectropion, distortion of alse ot the nose,
and microstoma, barely admitting a teaspoon.

Attempts had been made elsewhere to skin-graft portions of the face, and the appearance
on admission is shown in fig. 757 (22.8.18).

With a view to softening the scar and improving its blood supply, a thorough course
of X-ray and diathermic treatment was undertaken. This led to a definite improvement,
and by "27. 3. 19 the prospect of operation appeared favourable.

This case is important, as being the first in which a postauricular flap was used ; and
it may be of interest, at the risk of some repetition, to insert here the stages by which the
decision to use it was arrived at :

In the first instance (Case 338) a " Masonic collar " flap was taken from the chest, on
two pedicles which were tubed at the time of the operation.

Though successful, it was considered that in subjects of inferior physique the demand
made on the blood supply might prove too great.

Accordingly, in Case 364 another Masonic collar-flap the pedicles were tubed
first, and the flap turned up after three weeks' interval.

In Case 513, a unilateral area from chin to left ear required covering. After tubing,
a long single-pedicle flap was turned up from the chest and applied to an area, rawed for
its reception, upon the chin. Grave doubts were entertained as to its viability, at this
stage ; but in the second stage the severance from its original base, and the spreading
of the opened-out pedicle upon the cheek there was never a moment's misgiving.
Apparently the introduction of a new blood supply into tissue (especially when it is grafted
upon the face, the most vascular site of all) has a powerful stimulatory effect.

In view of this experience it was decided (Case 565) to lessen the demands on the
pedicle by shifting its upper end (its future base) closer to the first objective, to begin with.

After an interval of three weeks for its establishment in its new situation, its lower
end was brought up to the chin. The result of this manoeuvre was highly satisfactory ;
when a firm hold had been taken upon the chin, the original base, plus an extra area
from the posterior triangle of the neck, was swung up to the nose, and after a suitable interval
the pedicle was opened out and spread upon the cheek.

To return now to Case 1002. As the preliminary shifting of the upper end of the tube-
pedicle seemed to be so helpful in the last case, it was decided here to adopt a similar plan.
While considering the site of this preliminary shift, the author realised the futility of
being wedded to flaps from below the face, the bases of which would always need shifting.
Why not go higher at once ?

It happened that in this case the area of hair-free skin behind the ear was relatively
wide, and, further, was freckled in a manner similar to what remained of normal face
skin ; and so a post-aural flap was decided upon. (It should be noted that this flap is not
always available, nor, when available, is it always suitable.)

To obtain sufficient width, the skin over the posterior surface of the pinna was removed
in continuity with that over the mastoid, and the width was still further increased by the
inclusion of a small area of hairy scalp a slight disability, but of no great import in a light-
skinned subject.

Having shifted the base of the flap first, the intention was to tube a portion of the neck
and chest if necessary, and then swing this tube up to complete the facial restoration, the
final blood supply IK ing through the new cheeks.

On the left side, the scar tissue over the cheek was excised (the dissection in places
going very deep), and the shape and size of the flap were nicely adjusted to fit this area.

INJURIES IN THE REGION OF THE EYES

373

The requisite length of pedicle was carefully gauged, but the behaviour of flaps is not
always susceptible of mathematical analysis, and the colour of the flap was anxiously watched
during the process of dissection. When swung forward and sutured to its new position,
the flap turned very blue, especially that portion from the pinna, and hot saline dressings
were applied every two hours, beginning with the post-operative dressing.

After twenty-four hours the flap appeared to be going gangrenous ; but a remarkable
recovery occurred, and by the third day anxiety ceased. Only a small piece, from the
hairy scalp, failed to take.

Thiersch grafts, under moulded stent, were applied to the raw area behind the ear, but
with small success, owing to insufficient fixation of the mould.

On the right side the proceeding was similar, and the flap went through the same pre-
carious period. Here the scar was dissected from the face in one piece, and was applied
as a graft to the raw area behind the ear. After removal of slough, it was found that
valuable islands of epithelium had become adherent, considerably assisting the healing
process.

On these healthy and natural-looking new cheeks, flaps can now be swung up from
either side of the neck for the nose and chin. The eyelids will be dealt with by epithelial
outlays.

Note. These flaps are similar to the one employed in Case No. 215, p. 72, in the section
on cheeks.

FIGS. 757 and 758. On admission.

PLASTIC SURGERY

Fio. 759. Case 1002. Excision of scar and flap outlined.

l''n;s. 71)0 and 761. Restoration of both cheeks from post-aural region.

INJURIES IN THE REGION OF THE EYES

375

CASE 565

It is occasionally noticed that these epi-
thelial grafts suffer from a subsequent con-
traction, which would appear to be due to the
fibrotic process continuing in the bed on which
the graft is raised in other words, the graft-
ing is probably done too soon. Disappointing
results are therefore to be expected in very
severe burns, when the scar-tissue formation
is still active. Nevertheless, in order to get
the eye protected by a covering, it is a correct
procedure to perform one of these graft
operations. It is easy to do another at a
later date, and allowance should be made for
contraction.

In case No. 565 an excellent skin-graft
to the right lower lid and inner canthus region
resulted in 'a disappointment and a shrinking
to less than half its area. This would appear
to be due to the causes above mentioned.

Photographs are attached illustrating the
condition and area of the graft shortly after
the removal of the mould, while that of three
months later shows the contraction that has
occurred.

This case has been complicated by ulcers
on the cornea, rendering immediate procedure
to obtain a covering advisable.

FIG. 762. On admission.

Fio. 7G3. Shortly after outlay to
right upper lid.

FIG. 764. Three months later.
The outlay has contracted.

The next three cases are of burns, the interest of which lies in the
repair of the eyelids, by the epithelial outlay operation. There is nothing
special to describe about the operations, as they conform, in practically every
detail, to the type operation in the beginning of the chapter.

37G

PLASTIC SURGERY
CASE 557

Epithelial outlay operation for eyelids, performed on 16.5.18, fourteen months after
the result of the burn. Photographs illustrating the eyes, closed and open, before and
after treatment, require no description.

Right eye.
Open.

Closed.

FIGS. 765 and 766. Before treatment.

FI03. 767 and 768. Soon after operation.

Flos. 769 and 7 70. Final result.

INJURIES IN THE REGION OF THE EYES

377

CASE 633

Case 633 shows the result of burns in action, received on board one of H.M. monitors.
The nose and right ear were also burned and have not yet been treated ; but the ectropion
of the eyelids has been cured by the epithelial outlay.

The little fold observable in the open position after operation could be easily rectified
by simple excision, without interfering with the result.

Closed.

Right eye.

Open.

FIGS. 771 and 772. Before treatment.

FIQS 773 and 774. After treatment.

378 PLASTIC SURGERY

CASE 386

This was the patient who stated that he had been burned by a German flame-thrower.
But, as the accuracy of this information is not determined, the causative agent is
regarded as unknown. From its appearance, one would judge it to be an acid burn.

The main area affected was the chin, which was the seat of a large keloidal scar. Ex-
tending from the extremity of this were two scar lines running in to the nasolabial fold.
Tin- lower lip was markedly ectropic, the mucous membrane red, glazed and studded, with
mucous vesicles. Below the chin scar the burn extended down the neck and chest, gradually
diminishing in severity. On the face area involved the burn seems to have affected certain
spots much more than others, and often an island of healthy skin would be lying at the
bottom of a pit, the walls of which were composed of dense keloid.

Treatment. The deep portion in the left nasolabial furrow was first excised and the
skin approximated. Then the mass of the keloid on the chin was freely removed, together
with a redundant portion of the lower lip. A flap, with its base towards the posterior
triangle of the neck on the left side, was taken from the area as shown in the illustration,
fig. 776, and was swung up to the chin. The whole of the pedicle was sewn into the neck,
and, to make room for this, some of the scar tissue in the neck was cut as a flap and transposed
downwards to fill up the raw area. The post-operative stage was interesting, on account
of the effect of electro-therapeutic measures carried out soon after the operation ; they
were mostly in the form of the vacuum high-frequency electrode. At the end of the third
day a considerable reaction was noticeable in the way of increased blood supply to the
flap. This may, or may not, have had a detrimental effect, as the return veins and efferent
lymphatics were not sufficiently developed to carry off the fluids of this reaction, and stasis
became apparent on the third day. To aid the efferent circulation I discontinued the electro-
therapeutical measures, and pricked the bluer parts with a fine, sharp needle. Over this
pricked area Bier's cupping was applied, and much blood and lymph were extracted. The
colour and circulation immediately returned right to the extremity of the flap, but twenty-
four hours afterwards the blueness had returned to a minor degree along the extremity of
the flap and was not any longer amenable to treatment.

The amount of the flap lost by gangrene is well shown in the photograph, fig. 776. This
loss was sufficient to cause a slight pulling down of the lip opposite that spot, and, to cure
this and raise the lip, a nasolabial flap was later swung down below the margin of the
lower lip. At the same time the thick scar band from the right aspect of the mandible,
extending down the neck to the clavicle, was treated by skin-graft in the following manner,
which is similar to the treatment for ectropic conditions of the eyelids. An incision was
made right across the scar part, which was dissected out. The cavity was deepened until
the neck could be stretched and extended, the usual mould of the cavity taken, and a skin-
graft wrapped around it. The mould on this occasion was made of paraffin wax, and the
skin-graft was a Wolfe graft.

The result was satisfactory both as regards appearance and function.

7.12.17. Operation. Main principle. Excision of scar tissue and replacement by
a long broad chest-flap, having its base of attachment in the left posterior triangle of the
neck.

Details. The scar in the left nasolabial furrow was excised and the skin approxi-
mated. Primary union. That on the right was left untouched. The excision of the scar
commenced at each corner of the mouth and was carried outwards until healthy skin was
reached. A portion of the everted mucous membrane of the lower lip was excised with
the scar tissue about \ in. The scar tissue varied in depth ; in places there was even
healthy skin ; in others, the scar tissue extended deep into the muscular layer and was
quite \ in. in thickness. The long flap was outlined as in the diagram and swung into
position. It was stitched all along the healthy margin of the skin and mucous membrane.
In order to fit it in better, the portion of the front aspect of the neck which contained a
considerable amount of scar tissue was raised and swung downwards to help fill up the gap
on the chest.

INJURIES IN THE REGION OF THE EYES

379

FIG. 775. On admission.

Fio. 776. Chest flap to chin. (See text.)

Progress. The blood supply of the flap was good, but considerable swelling occurred
on the second and third days after the operation, which was due to the following causes :

Lymphatic and venous stasis of the extremities of the flap occurred. Blood and serum
collected under the flap, which was therefore drained beneath the chin. Portions of the
flap namely, just below the lip, and another patch on the right and another smaller patch
on the left became blue with a tendency to become gangrenous. The vacuum high-
frequency electrode was applied to the flap for the first three days after the operation.
On the third day pricking of the blue portions of the flap was resorted to and Bier's cupping
was carried out. Large quantities of lymph and blood were drained away, and the whole
contour of the flap improved considerably, almost to the normal. Hot fomentations were
applied and the electrical treatment discontinued. This treatment was continued for the
next two or three days, but gradually a line of demarcation appeared round each place,
followed by suppuration and sloughing.

17.6.17. Condition. There was some ectropion of lower lip, right corner, due to the
small portion of the chest-flap which sloughed at the previous operation. In addition,
along the right-hand edge of this flap was a thick band of scar tissue which prevented the
head being freely extended.

17.0.18. Operation. (1) After excision of scar near the angle of the mouth, flap
" A " from the right nasolabial fold was brought down to raise the corner of the lip. (2)
To divide the band of scar tissue satisfactorily a free incision was made across it, and a
cavity made into which a mould of a high-melting paraffin was inserted. A whole-thickness
graft from the arm was wrapped round it and the whole buried. There resulted complete
relief from the limitation of extension of the head, and a slight improvement in the
appearance.

:38()

PLASTIC SURGERY

Fio. 777. Indicating site of second operations. A whole-
thickness graft was applied after excision of the scar "B."

FIG. 778. Note scar near right corner of mouth.

Fia. 779. Final : After excision of scar and descending nasolabial flap.

INJURIES TO THE PINNA

DEFECTS and burns of the pinna form a small proportion of facial injuries.
The gunshot injuries met with may be thus classified : Scars, perforations,
marginal losses, losses of the lobule, and large and total losses of the pinna.

Scars do not always need treatment : owing to the breadth of the patient's
head relative to the width apart of the observer's eyes and the distance at which
ordinary conversation is conducted, it happens that both ears are seldom seen
in the same glance. Consequently, minor degrees of asymmetry are negligible.

Perforations of the concha readily lend themselves to repair by means of
a flap swung from the back of the pinna, as indicated in figs. 780-783.

Fio. 780. Perfora-
tion : Ascending
flap outlined.

Fio. 781. Flap
being swung
up.

Fio. 782. Per-
foration
closed.

Fio. 783 .
Raw area
grafted.

Marginal losses present more difficulty : the contour of the helix must
be restored. In small losses the author has successfully applied the principle
of turning up a flap from the back of the pinna containing a previously buried
piece of cartilage, after the method outlined in figures 784-787. Case
No. 622 was treated in this manner. (See photographs, figs. 788 and 789.)

If merely a small piece is required, the cartilage is taken from the same
or the other concha, where experience shows that the removal is not followed
by disfigurement. Otherwise, it is taken from the rib and suitably shaped.

381

PLASTIC SURGERY

CASE 622

Operation notes :

1.12.18. Piece of cartilage from anti-hdix of left car was removed subcutaneously
of the necessary length and curve to complete the gap in the pinna. (This through an
incision along the border of the anterior surface.) The cartilage was now imbedded into
a flap on the posterior aspect of the pinna, which is to be swung upwards as a skin-cartilage
flap later.

3.3.19. Replacement of missing portion of helix of left ear by flap from post-
auricular region.

21.5.19. Piece of cartilage from right anti-helix dissected and implanted to form
free border of new portion of left ear.

1.6.19. The top edge i s curved back a little. Patient not desirous of further treatment.

FlO. 784. Showing
defect ; Cartilage
implanted and
flap outlined.

FIG. 785. Flap
being swung
up.

FIG. 786. Flap
in position.

FIG. 787. Raw
area grafted.
(In Case 622 a
flap was used.)

Fio 7S8. Showing marginal defect.

Fio. 789. Present condition. Requires trimming
up to complete.

INJURIES TO THE PINNA

.'38.'}

Larger marginal losses are amenable to a type of repair comparable with
this, but on a larger scale.

Here, as in the cases of total loss, the principle employed is the preliminary
reconstruction of the missing organ by imbedding cartilage under the skin
bordering on the defect, followed by the elevation of the new pinna into position
as a second step.

In Case No. 3,357, a subtotal loss (see figs. 795 and 796), the support of the
new pinna was accurately fashioned in cartilage taken from the seventh and
eighth ribs.

This was inserted beneath the hair-free skin over the mastoid process and
the skin pressed down into its irregularities by means of Stent. Unfortunately,
the pressure thus applied proved too much for the blood supply, and much of
the cartilage forming the helix and anti-helix sloughed. The result of this
stage is shown in fig. 797.

Four months later a flap containing this cartilage was swung outward
and forward on a pedicle consisting of the stump of the original pinna.

The resulting raw area on the back of the new pinna and over the mastoid
process was covered by a flap taken from the posterior triangle of the neck.
The man's present condition is seen in fig. 798. The diagrams .of these stages
are indicated in figs. 790-794.

Operation notes of this case are as follows :

13.2.19. Otoplasty. Implantation of cartilage to left ear.
6.6.19. Plastic to left ear.

6.8.19. Blood examined. Pathologist'*- report: strong positive,
some bearing on the fate of the graft.)

(This may have

FIQ. 790. Rib - cartilage
shaped to represent miss-
ing portion.

FIG. 791 .Shaped car
tilage graft inserted
subcutaneously.

FIG. 792. Skin sutured over the graft.
Stent was applied to press the skin
accurately into the hollows.

384

PLASTIC SURGERY

()/ CASE 3357

Fio. 793. Operation four months after cartilage im-
plant. Skin-cartilage flap swung forward. Raw
area to be covered by flap from posterior triangle.

Fio. 795. Showing subtotal loss of pinna.

FIG. 794. Suture. The raw area on the neck
was easily covered by advancement of the edges

FIG. 796. Lateral view.

FIG. 797. After cartilage implant. (Much of it
sloughed. ? due to blood condition. See notes.)

FIG. 798. Present condition.

INJURIES TO THE PINNA

385

Loss of the lobule has been made good by means of a post-auricular flap which is made
to form the anterior surface of the lobule, the posterior covering being supplied by skin-
grafting the raw area.

Case No. 2251 was treated in this way, and the stages in the sufficiently
good result obtained are seen in figs. 803-805.

The operation notes for this case are as follows :

6.2.19. Post-auricular flap incised and turned up, having as its pedicle the remaining
portion of the ear. An incision was then made about 4 in. long at lower adherent
portion of ear, and part of the flap was sutured to this incision. The raw portion of the
flap and the bed of the flap were covered by a Thiersch graft under stent.

14.5.19. The lobular portion of the left ear was advanced about J in. by a vertical
incision.

Diagrams illustrative of the method employed in this case are given, and
diagrams for an alternative method are also shown.

FIG. 799. Showing defect,
and outlining of flap.

FIG. 800. Flap being
swung forward.

FIG. 801. Suture.

FIG. 802. Graft to
raw area.

It will be realised that the diagrams throughout this section are what
might be termed " ultra-diagrammatic." They were prepared from a verbal
description, as it was found that photos of some of the stages failed to give
any idea of the procedure adopted.

38(5

PLASTIC SURGERY

CASE 2251

Fio. 803. Showing the defect.

Fia. 804. Soon after plastic.
Side view.

Fia. 805. Soon after plastic. Posterior view. The Thiersch graft failed to take in parts.

Fio. 800. Showing defect,
and proposed flap outlined.

Kid. 81)7. Flap swung down FIG. 808. Suture. Fio. 809. Raw area

and being doubled upon itself. grafted.

SUGOESTKD ALTERNATIVE METHOD OF MAKING THE LOBULE.

INJURIES TO THE PINNA 387

Burns are often followed by adhesions of the remnants of the pinna to the
skin over the mastoid process. Here the epithelial inlay is indicated, and in
cases with small loss of substance the freeing of the pinna produces a sufficiently
satisfactory result.

CASE 3359

FIG. 810. Shows result of epithelial outlay used as a means of freeing the upper portion of the
pinna which was adherent to the scalp. (Photo of pre-operative condition not available.)
The limits of the outlay can be seen with difficulty.

Operation notes :

20.9.18. Right pinna dissected from scalp to which its upper portion was adherent.
Mould of raw cavity thus formed taken with warm stent. Thiersch wrapped round stent,
raw area outwards, and placed in the cavity. Free edge of pinna sewn back to original
position against scalp.

30.9.18. Stitches cut, stent removed. Graft taken nicely.

In these burnt cases there is usually so much concomitant scarring that
local flaps are not available, and the question of the expediency of restoring
the pinna by neck or chest flaps is intimately associated with the problem
of the whole facial restoration. It is found, as a matter of practice, that the
ear defect in a severe burn is a minor part of the disfigurement, and does not
usually justify the time and trouble that its cure requires.

PLASTIC 8URGEEY IN CIVIL CASES

389

CHAPTER VIII
PLASTIC SURGERY IN CIVIL CASES

THE application of the methods described and discussed in the previous pages
will, in the author's opinion, have considerable effect upon the possibilities of
plastic surgery amongst the civil community. It may be also, that, apart from
the much wider field of deformities which will be brought into the class in which
successful restoration can be applied, the treatment of the disease itself, in
addition to the deformity caused by the disease or injury, will be modified.
Thus, when it is demonstrated that successful and cosmetic rhinoplasty is an
operation that can be counted on with reasonable certainty, the early treatment
of lupus may be modified in the direction of complete excision of the affected
area regardless of the deformity so caused.

Should this suggested line of treatment be practical in removing the disease,
years of local therapy will be dispensed with.

Many of the cases that the author has treated for healed lupus deformities
had a history lasting for ten or fifteen years, and presented tissues so scarred
and fibrosed that the work of the plastic surgeon was greatly hampered. Had
it been possible, in such cases, to have excised the tip of the nose with the
adjacent lymphatic tracts in the naso-labial folds completely in the early stages,
successful nasal reconstruction, with far less resultant deformity, could be reason-
ably guaranteed, and the treatment markedly shortened.

Taking the situation as it is at present, there are many thousands^of cases
in the world of healed lupus whose scarred facial remains are so distorted that
most of them have to live a secluded or semi-secluded life.

Even in this scarred class of case gratifying results of rhinoplasty have
already been obtained by the author.

It is found advisable to modify somewhat the plan of treatment in these
cases, particularly in regard to two points.

One of these points is that the inturned flaps to form the skin lining of the
new nose have to be so designed that they have a larger blood supply than is
usually deemed sufficient in the non-lupus cases.

The second point is that the tissues are more liable to suppurative troubles,
and it is unwise to take the risk of immediate cartilage implantation between two
epithelial flaps.

Examples of this are given among the cases which follow.

391

392 PLASTIC SURGERY

Turning to syphilis, as the principal peace-time destroyer of the nose, the
author has not yet seen a case which is not amenable to the methods evolved
by him during the war.

These cases appear to be quite comparable with the war injuries, provided
that diagnosis is made of the tissue lost, and repair is designed to make good
such losses ; and the results are very encouraging.

In one of the cases illustrated the main loss of tissue was in the mucous
membrane lining. There was also concomitant loss of the cartilage supports,
while the skin covering was almost intact.

The provision of a skin-graft for the lining and cartilage for the support
was sufficient to produce a good result.

In a second case of hereditary syphilis total loss of the nose existed. All
structures, including the bony supports, lateral and central, had been destroyed
by the disease. The early result of rhinoplasty in this case is illustrated.

Depressed fractures of the nose, either with or without lateral deviation, are
best treated by cartilage implantation. In some cases, however, especially
where there is lateral deviation only, it is possible to refracture the nose and
set it straight. Naturally the surgeon will pay attention to the freeing of the
airway in all cases.

In regard to hare-lips, the author does not intend to discuss the early
operative treatment which is so fully known and appreciated by the surgical pro-
fession. It has, however, occurred in the author's practice to treat a number
of cases the results of whose early operations, good though they are, were
capable of being treated on lines similar to those suggested in this book.
Corrections of the line and the contour of the new lip, and the position of
the columella and alse can quite often be effected, while interpolation of an
epithelial inlay will often produce a contour which effects an astonishing improve-
ment.

Burns of the face are a common injury in civil as in military practice,
and do not require special treatment in this chapter.

The author's operation for epithelial outlay has already produced a great
relief to patients afflicted with cicatricial ectropion. The possibility of removal
of nsevoid disfigurements springs to one's mind, and many such are amenable to
the newer methods.

Rhinophyma obviously lends itself to most gratifying rhinoplasty, either by
forehead flap or Wolfe graft.

Over-developed and under-developed noses can be corrected without scarring
or any secondary disfigurement.

A few examples of completed and semi-completed cases of facial dis-
figurement are appended.

PLASTIC SURGERY IN CIVIL CASES 393

The principles the development of which has been indicated by this book
are, naturally enough, not applicable merely to facial surgery. The principle
of tubing the pedicle of a flap has, at one bound, pointed the way to dealing
with a reasonable loss of skin, traumatic or pathological, from any part of the
body surface. Skin may be brought by this means from any part to any other
in one step for distances not exceeding ten inches otherwise in several
steps, the source and direction of the blood supply being changed each time
the existing base becomes the free end.

It should even be possible to establish a satisfactory ambulatory treat-
ment for varicose ulcers.

The surgeon may now deal fearlessly with almost any ulcer that can be
excised or rendered clean, secure in the knowledge that a covering of healthy
skin can be provided for the raw area resulting from his interference. Further,
it is not too much to say that contractures should not now be allowed to occur
after burns. The impending deformity can be anticipated by a thorough
excision of scar tissue followed by the use of skin -flaps, tubed, say, three weeks
before, from the periphery of the defect. Webbed fingers and other similar
deformities should present problems now greatly simplified.

The tubed flap may be made to bear within its substance or upon its sur-
face supplies of skin, hair, mucosa, fat, connective tissue, bone, cartilage or
blood-vessels in fact any of the less highly organised tissues. There is scope
for the transplantation of such material in the restoration, not only of surface,
but of tissues bordering thereon. The gap left by the removal of the female
breast should be remediable in terms of tubed flaps designed to carry large
masses of fat, e.g. from the buttock, along the lines indicated in figs. 811 to 816.

The principle of replacement in kind for lining membranes as for coverings
finds a field wherever trauma or disease have transgressed the barriers that
separate these two types of tissue. Thus a severe degree of stricture of the
urethra should lend itself to excision followed by the reconstitution of the
mucosal lumen by a Thiersch graft applied by some modification of the Esser
Inlay.

In this connection, pre-natal disease offers a vast field. Conditions such
as Ectopia Vesicte, Hypospadias, Meningoccele, Imperforate Anus, and various
forms of fistulse offer scope for the application of these principles in combination.

394

PLASTIC SURGERY

Flo. 811. Breast excised ; flap outlined.

Fio. 812. The pediole "tubed."

tt< -The fat-carrying flap being swung up to the defect,.

MKTHOD OF HESTORING THE CONTOUH OF THE BREAST AFTER EXCISION.

PLASTIC SURGERY IN CIVIL CASES

395

FIG. 814. The flap sutured into place.

FIG. 815. The pedicle severed, opened out, and being
swung up to reinforce the flap.

FIGS. 81 1 and 812 represent the first stage,
which would be followed by an interval
of at least ten days.

FIGS. 813 and 814 represent the second
stage, also followed by a ten-day
interval.

FIGS. 8 1 5 and 8 1 6 represent the final stages.

FIG. 810. Suture.

J39G

PLASTIC SURGERY

FIGS. 817 and 818. Hereditary specific disease : total destruction of nose. In these photographs a piece of
cartilage has been imbedded above the nasal aperture, and a thin piece laterally in each naso-labial fold to form
the bridge and ala supports respectively.

Flos. 819 and 820. Early result : Rhinoplasty from the forehead by tubed pedicle method.

Fio. 821. Dog bite of lip.

Fid 822. Result of sewing small flap into lip
to replace scar.

PLASTIC SURGERY IN CIVIL CASES

397

Fios. 823 and 824. Acquired destruction of nose. (Paraffin had been injected to raise the bridge.)

FIG. 826.

FIG. 825. FIG. 827.

FIG. 825. Intermediate. Intermediate stage, showing result of skin-graft to inside of nose. The skin-graft was
inserted from an incision beneath the lip, held in position by stent mould, which, in itself, was held in position by
a dental splint passing through an existing palatal perforation. The nose is here seen supported by a dental
appliance taking its purchase from the upper teeth, and supporting the bridge through the palate. This
appliance was made and designed by Major Kenneth Russell, A.A.D.C.

FIGS. 820 and 827. Finals: Result after cartilage implantation. Cartilage taken from another case and inserted
through the tip. The appliance to the nose is worn no longer, as the cartilage is sufficient.

898

PLASTIC SURGERY

Fios. 828 and 829. Traumatic loss of the tip, eolumella, and also of the nose. Much forehead scarring,
and part loss of upper lip. (There had been previous attempts at restoration.)

FIGS. 830 and 831. Finals : Result of rhinoplasty.

I n.. s:t:!. Kxrussive prominence of nasal bridge.

Flo. 833. After operation by excision.

PLASTIC SURGERY IN CIVIL CASES

399

FIGS. 834 and 835. Traumatic deformity of nose.

FIGS. 830 and 837. Result of cartilage implantation.

FIG. 838. Arrested development of nose
from natal injury.

FIG. 839. Result after cartilage
implantation.

400

PLASTIC SURGERY

FIGS. 840 and 841. Deformity of nose following lup

Fio. 842. Rhinoplasty by temporal artery
tube pedicle flap.

FIQS. 843 and 844. Result of rhinoplasty.

INDEX

Acid burns, 347
Advancing flaps, 19, 20

in rhinoplasty, 214, 248

in upper lip injuries, 101
After treatment, 34
Airman's burns, 347, 372-375
Air-way, nasal, bleeding into, 27, 28

clearing of, 213

establishment of, 271, 278

Hewitt's, 27, 28

obstructed, ansesthesia with, 27
due to loss of columella, 202
Ala, injury to, author's method of treatment, 258
Wolfe graft in, 247

loss of, 246, 398

cases illustrating, 247-257

new, provision of, 252, 255, 263

operation on, 225

partial loss of, 267, 269

pug-nose deformity of, 230, 231
cases illustrating, 232, 237-239

skin lining for, 212
Alveolar process, loss of, 64
Alveolus, palatal injuries involving, 207
Anaesthesia, 23

chloroform and oxygen, in sitting-up position,
24

coughing during, 26

for rhinoplasty, 27

intra-tracheal, 23

nasal tube for, 25

oil-ether, 27, 28

paraldehyde, 28

position during, 24
Anus, imperforate, 393
Appliances. See Prosthetic appliances
Approximating hooks, 50
Ascending flaps, 19

for upper lip injuries, 77, 78, 80

in ear injuries, 381

in eye injuries, 314
Asepsis, during suture, 33
Autologous cartilage graft to nasal bridge, 293
Autologous osteochrondral mandible graft, 179,
180, 181

Ball cartilage eyes, 336, 339
Bird-beak type of nose, 217
Blepharoplasty, inferior, 313

flaps in, 314
principles of, 313
superior, 329
cases illustrating, 330-331

Blepharoplasty, principles of, 329

suture in, 315

Blood supply of Haps, 30, 77-79
Bone grafts, 183-189

anaesthesia during, 28

restricted use of, 12

to the mandible, methods, 177-180
Bony chin, loss of, 123
Bony loss, estimation of, 5

extensive, 198

in cheek and jaw injuries, 52, 64
cases illustrating, 52-63, 64-74

in eye injuries, 301, 304, 306, 308

prosthetic replacement of, 200
Bridge pedicle Haps in upper lip injuries, 98, 115.

See also Pedicle
Buccal fistula, 50, 70
Buccal orifice, widening of, 132
Buccal restoration, 8, 9
Burns, cases illustrating, 353-380

after treatment of, 351

causes and varieties of, 347

facial, 18, 347, 349

causing microstoma, 123

of the ears, 347, 381

of the eyelids, 347, 349

treatment of, 348, 349
errors in, 351

Canthoplasty, 324, 325

method of obtaining, 13
Cartilage flaps, in eye injuries, 315

in nose injuries, 217, 230, 231, 234, 258

in pinna injuries, 382, 384
Cartilage grafts, 12, 13

homologous and autologous, 13, 14, 15

in cheek injuries, 45

in eye injuries, 303, 307, 309, 338, 344

in operation for orbicularis palsy, 344

in pinna injuries, 383

Cartilage implants, for depressed fractures of
the nose, 392

in extensive cheek injuries, 73, 74

in eye injuries, 336

in inferior blepharoplasty, 314, 315

in pinna injuries, 383-384

in nose injuries, 212, 219, 223, 227, 264, 266,
268, 399

to malar region, 309

Cartilaginous supports, skin-flaps used in associa-
tion with, 22
Caterpillar movement, in nose repair, 250, 251

401

INDEX

Catgut sutures, 32

Olluloul plate, for facial contour, 12

in cheek repair, 52, 53. ."> I
Celluloid supports, Indian rhinoplasty over
Check, adherent to palate, 207

excision and incision of scars of, 61, *>6, >J.
loss of bony framework of, 52
mucous flap from inside of, 139
reconstruction after nasal operation, 212
repair of the, 37

Cheek-Haps, in lip injuries, 87, 129, 1
in injuries to palate, 207
in rhinoplasty, 3
Cheek injuries, 37-38

celluloid implantations in, 53, 54
complete loss in, 71, 72
depressed scars, 37, 38

cases illustrating, 39-41
extensive destruction in, 72
extensive loss of soft parts, appliance used in,

195

fat-grafts in, 44

hollow filled by fat-graft in, 115
horsehair mattress sutures in, 57
loss of soft tissue only, 42
cases illustrating, 42-51
restoration from post-aural region, 374
sutures in, 63, 65
teeth carried through, 50
total loss of nose with, 294
triangular opening in, 60 j
with loss of bone, 52, 62

cases illustrating, 52-63
with superior maxillary loss, 64

cases illustrating, 64-74

Chest, tube pedicle rhinoplasty from, 212, 213
Chest-Haps, for facial losses, 14, 352
in rhinoplasty, 212, 213
to chin, 370, 379

Chin, anesthesia during operations on, 26
new, operation for provision of, 175
prosthetic replacement of, 174
viability of llaps near, 22
Chin-flaps, for upper lip injuries, 78, 80, 90
Chin injuries, 123, 124, 158

cases illustrating, 125-189
chest llaps in, 370, 379
descending nasolabial cutaneo-muscular flap in,

160

excision of scar tissue in, 165
extensive loss in, 162, 168, 172
forehead flap in, 176
neck-Hap in, 159
scalp-Hap in, 170
scar excision in, 164, 167
soft tissues, 165, 166, 172
suture in, 157, 163, 164, 167
Chloroform and oxygen anaesthesia, methods, 24-

technique, '2 I
Civil rases, plastic surgery in, 391

illustrations of. :t'.l 100

Cleft palate, aiia-slhesia during operations on, 25
Colmnella. and upper lip repair, 82
artificial, 203. 27.'), 2*7
celluloid support to, 22li
deficiency of, 253

Columclla. detachment of, 252

loss of, 398

obstructed airway due to loss of, 202

operation on, 95
Concha, perforation of, 381
Conjunctiva, deficiency of, 332

incision through, 332, 333
Contour. See Facial contour
Cordite burns, 347

Coughing, prevention during anaesthesia, ^o
Covering tissues, 16

Cranial defects, loss of bone constituting, 301
Cyanosis during anaesthesia, 24, 25

Deformity, scar tissue in relation to, 30
Deglutition, impaired, 124
Dental appliances in palatal injuries, 205,
Dental fixation, nasal splint with, 201
Dental splints, 194

in mandible injuries, 177, 195
use of, 194-196
use in epithelial inlay, 10
Dental sulcus, reformation of, 197

prevention of encroachment of soft tissue

upon, 196

preservation of, 194, 195
Dental surgeon, role of, 6, 7, 10, 193, 206
Dentures, 193
functional, 200

in upper lip injuries, 82, 83, 92, 93
prosthetic support of, 200
with artificial pre-maxilla, 92
Depressed scars of the cheek, 37-38
Depressor musculature, for the jaw, 123, 124
Descending flaps in eye injuries, 314
in lower lip injuries, 142, 148, 150, 154
in upper lip injuries, 78, 97, 103
Descending naso-iabial flaps, 19
Diagnosis, data for, 5

depending on accurate estimation of tissues

lost, 146
mistakes in, 4

Digastric, epithelialisation of, 124
Dressings, 33

Ears, burns of, 347, 381

flaps from, in blepharoplasty, 313

injuries to, 381
flaps in, 381

restoration of lobule of, 386

See also Pinna injuries
Ectopia vesicse, 393
Ectropic conditions, epithelial outlay an, K

modification of epithelial inlay in cure of, 9
Ectropion, 354, 355, 358, 361, 362, 363

cicatricial, following burns, 349, 354
treatment of, 349

of lower lip, 125

of upper lip, 115

traumatic, 313

Wolfe graft relieving, 366
Electrical post-operative treatment, 34
Electric burns, 348
Entropion, 332

Epicanthus following burns, 351
Epilation, 9

INDEX

403

Epiphora, due to orbicularis palsv, 344
Epithelial inlay, 9-12

advantages of, 200

anaesthesia during, 25

for stenosis of anterior nares, 213

in eye injuries, 325, 332

in mouth injuries, 200

new nasal tip and alse by, 263

splint with ilange to maintain stent for, 197
Epithelial lining, in nose injuries, 221

provision of, 8
Epithelial outlay, 16

in ectropic conditions, 16

in eye injuries, stages of, 350, 363

in eyelid injuries, 289, 330, 331, 349, 358, 376

in pinna injuries, 387

stages in, 17

Esser inlay. See Epithelial inlay
Ether anaesthesia, 27
Ether swab, preparation of skin for operation by,

Examination of cases, principles of, 4
Excision of facial wounds, 6
Extra-oral appliances in nose injuries, 201, 202,

203
Eye injuries, 203

bony loss in, 304, 306, 308

cartilage grafts in. 303, 307, 309, 338

cranial loss in, 306

epithelial inlay in, 325, 332

epithelial outlay in, 349
stages in, 350, 363

failures in operations in, causes of, 322

flaps in, 304, 318, 328, 358

infra-orbital depression, 311

pedicle flaps in, 309, 358, 362, 365, 369

prosthetic appliances in, 203-205, 335

orbital ring, 301

scar excision in, 202

suture in, 302, 308, 323

temporal flap in, 308

Tripier operation in, 59

See also Blepharoplasty
Eyebrow, artificial, 301

loss of, 301, 304

replacement of, 18, 301
Eyes, artificial, 336, 337

insertion of, 204, 340, 342
cases illustrating, 338-343

burns of, 347-349

flaps near, 19

paralysis of muscles of, 344

primary enucleation of, 336
Eyelashes, tattooing for, 329
Eyelids, artificial, construction of, 204

bums of, 347, 349

after treatment of, 351
cases illustrating, 353-380
errors in treatment of, 351
treatment of, 348, 349

destruction of, 313

distorted, replacement of, 316

ectropion of, epithelial outlay in operation for,
16, 17

epithelial outlay to, 289, 358, 376

incision in, 317

injuries to, 313

Eyelids, injuries to, cases illustrating, 316-331
lower, lack of muscle power in, 57
lymph-oedema of, 326, 328
operations on, 313
rebuilding of ocular aspect of, 8
reproduction of action of, 344
tattooing of, 329
upper, drooping of, 204

flap from, 314

loss of, 329, 330, 331

lymph-oedema of, 58

reconstruction of, 329
Eyesockets, contracted, 332

following defective rhinoplasty, 8
epithelialisation of, 203, 343

appliance for, 204
injuries of, 332

cases illustrating, 334
inlay, 325
replacement of, 74
sunken, 336, 341

cases illustrating, 338-343
Tripier operation on, 58, 59

Face, burns of, 18, 347, 349
cases illustrating, 353-380
errors in treatment of, 351
treatment of, 348, 349

deformity of upper part of, 194

destruction of greater portion of, 72

scars of, plastic treatment of, 391
Facial contour, building up of, 12-14, 193-195
skin-grafts in, 16

fat and muscle flaps for, 14, 30

loss of, extraordinary example of, 71, 72

observations on, 12

scar tissue and, 30
Facial scars, invisible, 33

Facial wounds, avoidance of secondary haemor-
rhage in, 7

cartilage grafts in, 14

early treatment of, 5-

excision of, 6

plan of restoration in, 8

planning the late repair of, 7

supporting structure for, 12

suture for closure of, 32
Failures in plastic surgery, to what due, 4
Fat-flaps, 30

in restoration of contour, 14, 30
Fat-graft, hollow in cheek filled by, 115

to cheek, 44

use of, 14, 16

Fat implants, in eye injuries, 336
Fatigue, prevention of, during operation, 29
Fistula, buccal, 50, 70
Flame-thrower, burns from, 348
Flanges for splints and dentures, 194, 196, 197
Flaps, about the eyes, 19

advancing, 19

ascending, for lip injuries, 77-78

blood supply of, 30, 77-79

cartilage supports and, 22

descending, for upper lip injuries, 78

descending naso-labial, 19

early cutting of, not recommended, 6

for facial burns, 352 ,

404

INDEX

Hups. forehead, 18, 176, 282

grafts sometimes more suitable than, 22

hair-l)caring, 9, 77

in chin injuries, 158, 160, 163, 170, 173, 176

indications for, 16

in car injuries, 381

in eye injuries, 304, 313, 314, 318, 324, 358,
365

in inferior blepharoplasty, 313, 314, 315

in injuries to palate, 207

in lower lip injuries, 125, 127, 129, 141, 148,
150

in mouth injuries, 94

in rhinoplasty, 211, 213, 217, 219, 230, 234, 248,
258

in pinna injuries, 381, 385, 386

in upper lip injuries, 78-82, 89

near the chin, 22

oedema associated with, 22, 34

preparation of areas for, 29

preservation of the life of, 22

principles of, 393

skin-muscle-mucous membrane, 148

suture and, 32, 33

transposed, 19

tubed, 19, 21, 213, 393

viability of, 22
Forceps, for suture, 31

Forehead, grafting of raw area on, after rhino-
plasty, method, 18
Forehead, skin-graft on, 297

Wolfe graft to, 273
Forehead flaps, in chin injuries, 176

in rhinoplasty, 3, 213, 275, 279, 282, 396
Foreign bodies, irritating tissues, 12
Fornix, lower, loss of, 335, 338
Frontal bone, injury to, with eyebrow loss, 304
Function, restoration of, importance of, 8
scar tissue impeding, 30

Glabellar region, cartilage imbedded over, 271
flaps from, in rhinoplasty, 214, 215, 217
prominence in, 223

Glass eye, skin-covered, insertion of, 340, 342

Grafts. See Skin-grafts

Granulation, prevention of, 6

Hiemorrhage, during administration of anaes-
thetics, 27

into air-ways, 27, 28

prevention of, during operation, 29

secondary, avoidance of, 7
Hair-bearing flaps, 9, 77-79

for lip injuries, 77
Hare-lip, 92

plastic treatment of, 392
Hare-lip type of injury, 106, 123, 124
Helix, restoration of contour of, 381
Hewitt's air-way, 27, 28
Hooks, approximating, 50
Horsehair suture, 31, 57
Hyoscinc MS preliminary hypodermic, 27
Hypospadias, 393

Ilium grafts, 1S8, 189

to the mandible, 178, 179, 180, 188, 189
Infra-orbital depression, 311

Intra-oral prosthetic appliances, 201

Intra-nasal supports, vulcanite, 276

Intra-tracheal amesthesia, 23

Invisible scars, 32

Iodine, preparation of skin by, for operation, 29

Japanese silkworm gut, 32
Jaw, anaesthesia for operations on, 27
injuries to, 46, 124, 134
artificial pre-maxilla in, 92
extensive loss in, 70, 71
new, depressor musculature for, 123, 124
ramus of, ulceration of membrane over, 180
upper, loss of bony support of, 64

Kahn's tube for administration of anaesthetics,

25, 26
Keloid scar of upper lip, 109

Labiogingival sulcus, re-creation of, 9, 182

Lachrymation, 344

Laryngotomy, 26

Lining membrane for deepened sulcus, 9

for mucous cavities, provision of, 3, 8

provision of, methods of, 9, 10
Lip injuries, adherence to palate in, 207

backward displacement in, 87

cheek-flaps in, 87

deformity with partial loss of nasal bridge and
ala, 240

dog bite, 396

flaps in, 84, 85

outer third drawn upwards and inwards, 60

repair and replacement in, 77, 80, 82, 83, 151,

152, 156, 175
suture in, 85, 242

vermilion border in repair of, 9, 81, 139, 151,

153, 156

cases illustrating, 138-139

with cheek destruction, 48, 49, 56, 57
Lip injuries, lower, 82, 123-124

anaesthesia during operations in, 26

bone grafting to the mandible in, 177-180

cases illustrating, 125-189

central portion, cases illustrating, 134-137

cheek-flap in, 129, 139, 141

descending naso-labial flaps in, 142, 150

diagnosis dependent on accurate estimation
of tissues lost, 146

ectropion in, 125

lack of control in, 124

mucous flaps in, 152, 156

naso-labial flaps in, 142, 148, 150, 154

neck-flap in, 159

provision of new lip in, 159, 169, 175

scar excision in, 135-137, 141, 143

suture in, 125, 130, 141, 149
Lip injuries, upper, 7782

anaesthesia during operations on, 24

bridge pedicle flap in, 115

cases illustrating, 83-119

chin-flaps in, 90

complete loss in, 7, 84, 85, 87

dentures in, 82, 92, 93

descending flaps in, 97, 103

ectropion in, 115

hair-bearing flaps for, 77-79

INDEX

405

Lip injuries, Keloid scar in, 109

laceration and drooping in, support for, 194

loss of soft tissue in, appliance for, 195

mucous (lap in, to lower lip, 153

nasal flaps in, 90

prosthetic appliance in, 85, 88

provision of mucous membrane in, 81

repair in, columella in relation to, 82

secondary corrections in, 80

six-flap operation in, 89

suture in, 93, 97, 101, 103

total loss in, 82, 83
Lupus, deformity of nose following, 400

plastic treatment of, 391
Lymphatic stasis, 22

Malar, cartilage implant to, 309

loss of, 54, 301

large hollow produced by, 58

partial loss of, 46

simulation of, 16
Mandible injuries, 177

anaesthesia during operations for, 24, 26

author's osteochondral graft in, 179, 181

autoflxation in, 177

autologous osteochondral graft in, 179, 180,
181

Billington's graft in, 179, 190

bone-grafts in, anaesthesia during, 28

clearly defined gaps in, 6

complete destruction in, 123, 158, 168

dental splints in, 177, 195

estimation of loss, 5

extensive loss in, 70

fracture, drainage of, 6, 7

grafting in, methods, 177-189

ilium graft in, 178, 179, 180

non-union in, 179

osteogenesis in grafts in, 34

osteoperiosteal grafts in, 177, 180

pedicle graft in, 178, 180

prosthetic replacement in, 158

re-creation of labiogingival sulcus in, 9, 182

rib-grafts in, 177, 179

summary of principles of grafting in, 180

tibia grafts in, 178, 179

union in, 70

Massage, dispersal of oedema by, 34
Mastication, essential problem in palatal injuries,

205, 206
Mastoid process, adhesion of remnants of pinna

to, 387

Mattress sutures in cheek injury, 57
Maxilla, anaesthesia during operations on, 24

artificial, 89

double fracture with downward displacement,
227, 229

downward displacement of, 203

extensive loss of, cases illustrating, 197, 198

falling in of soft tissues due to extensive loss,
197

forward rep'acement of, 195

fractures involving orbital plate, 203

loss of orbital plate of, 301

prosthetic appliances for, 203

prosthetic replacement of, cases illustrating,
196, 198, 199

Maxilla, replacement of, 227, 229

superior, loss of, 62, 64
cases illustrating, 64-74
prosthetic replacement of, 196, 198